HEALERS ABROAD

Americans Responding to the Human Resource Crisis in HIV/AIDS

Committee on the Options for Overseas Placement of U.S. Health Professionals

Board on Global Health

Fitzhugh Mullan, Claire Panosian, Patricia Cuff, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS HEALERS ABROAD Americans Responding to the Human Resource Crisis in HIV/AIDS Committee on the Options for Overseas Placement of U.S. Health Professionals Board on Global Health Fitzhugh Mullan, Claire Panosian, Patricia Cuff, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. SAQMPD04C1177 (STAT-6050) between the National Academy of Sciences and Office of the U.S. Global AIDS Coordinator at the U.S. Department of State. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on the Options for Overseas Placement of U.S. Health Professionals. Healers abroad : Americans responding to the human resource crisis in HIV/AIDS / Committee on the Options for Overseas Placement of U.S. Health Professionals, Board on Global Health ; Fitzhugh Mullan, Claire Panosian, Patricia Cuff, editors. p. ; cm. Includes bibliographical references. ISBN 0-309-09616-2 (pbk.) 1. AIDS (Disease)—Government policy—United States. 2. Medical assistance, American. 3. World health. I. Mullan, Fitzhugh. II. Panosian, Claire. III. Cuff, Patricia A. IV. Title. [DNLM: 1. HIV Infections—therapy. 2.Delivery of Health Care—organization & administration. 3. Health Manpower. 4. Health Personnel—education. 5. Health Planning. 6. International Cooperation. WC 503.2 I589h 2005] RA643.8.I575 2005 362.196′9792—dc22 2005014301 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2005 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: Institute of Medicine. 2005. Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS. Washington, DC: The National Academies Press. Cover: “Community Embroidery” by the Paper Prayers Campaign and the Artist Proof Studio, 2001. The Community Embroidery was commissioned in South Africa by the inter-government committee on AIDS to show their commitment to preventing the spread of HIV/AIDS. It was implemented by the Paper Prayers Campaign, an outreach project of the Artist Proof Studio in Newtown. The embroidery was designed by a student of the Artist Proof Studio and embroidered by the Chivurika Embroidery group in Giyani, Limpopo Province, South Africa. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS COMMITTEE ON THE OPTIONS FOR OVERSEAS PLACEMENT OF U.S. HEALTH PROFESSIONALS FITZHUGH MULLAN (Chair), Health Affairs/Project Hope and the Department of Prevention and Community Health, George Washington University School of Public Health and Health Services, Washington, DC MICHELE BARRY, Office of International Health, Yale University School of Medicine, New Haven, CT JANE Y. CARTER, African Medical and Research Foundation, Nairobi, Kenya LINCOLN C. H. CHEN, Global Equity Initiative, Harvard University, Asia Center, Boston, MA GARY GUNDERSON, Rollins School of Public Health, Emory University, Atlanta, GA MALCOLM BARRY KISTNASAMY, Nelson R. Mandela School of Medicine, University of KwaZulu Natal, South Africa RONALDO LIMA, International AIDS Vaccine Initiative, New York, NY LESLIE D. MANCUSO, JHPIEGO Corporation at Johns Hopkins University, Baltimore, MD WILLIAM MOORE, Clinical Professor of Medicine, Vanderbilt University, Nashville, TN ANDRE-JACQUES NEUSY, Center for Global Health, New York University School of Medicine, New York, NY JAMES B. PEAKE, Former U.S. Army Surgeon General and Project Hope Executive Vice President, Millwood, VA CHRISTINA POLYAK, University of Maryland School of Medicine, Baltimore, MD MARLA E. SALMON, Nell Hodgson Woodruff School of Nursing and Lillian Carter Center for International Nursing, Emory University, Atlanta, GA ROBERT T. SCHOOLEY, Division of Infectious Diseases, University of California, San Diego HARRISON C. SPENCER, Association of Schools of Public Health, Washington, DC Liaisons and Study Consultants THOMAS DENNY, Consultant RICHARD GUERRANT, Board on Global Health Liaison BJORG PALSDOTTIR, Consultant CLAIRE PANOSIAN, Senior Consultant/Writer KAI SPRATT, Consultant

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Staff PATRICK KELLEY, Board Director PATRICIA CUFF, Program Officer ALYSON SCHWABER, Research Associate/Assistant Editor DIANNE STARE, Research Assistant ALLISON BERGER, Senior Program Assistant

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS BOARD ON GLOBAL HEALTH DEAN T. JAMISON (Chair), Senior Fellow, Fogarty International Center, National Institutes of Health, Bethesda, MD, Professor of Education and Public Health, UCLA, Los Angeles, CA YVES BERGEVIN, Senior Program Advisor, Africa Division, United Nations Population Fund, New York, NY JO IVEY BOUFFORD, Professor, Robert F. Wagner School of Public Service, New York University, New York, NY DONALD BERWICK (IOM Council Liaison), Clinical Professor of Pediatrics and Health Care Policy, Harvard Medical School, President and CEO, Institute of Healthcare Improvement, Boston, MA DAVID R. CHALLONER (IOM Foreign Secretary), Vice President for Health Affairs, Emeritus, University of Florida, Gainesville, FL MARGARET HAMBURG, Consultant, Nuclear Threat Initiative, Washington, DC SUE GOLDIE, Associate Professor of Health Decision Science, Department of Health Policy and Management, Center for Risk Analysis, Harvard University School of Public Health, Boston, MA RICHARD GUERRANT, Thomas H. Hunter Professor of International Medicine, Director, Center for Global Health, University of Virginia School of Medicine, Charlottesville, VA GERALD KEUSCH, Assistant Provost for Global Health, Boston University School of Medicine, Associate Dean for Global Health, Boston University School of Public Health, Boston, MA JEFFREY KOPLAN, Vice President for Academic Health Affairs, Emory University, Atlanta, GA ADEL A.F. MAHMOUD, President, Merck Vaccines, Whitehouse Station, NJ MICHAEL MERSON, Anna M.R. Lauder Professor of Public Health, Yale University School of Public Health, New Haven, CT MAMPHELA A. RAMPHELE, Senior Advisor to the President, the World Bank, Cape Town, South Africa MARK L. ROSENBERG, Executive Director, The Task Force for Child Survival and Development, Emory University, Decatur, GA PHILIP RUSSELL, Professor Emeritus, Bloomberg School of Public Health, Johns Hopkins University, Potomac, MD JAIME SEPÚLVEDA AMOR, Director, National Institutes of Health, Mexico

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Staff PATRICK KELLEY, Director ALLISON BERGER, Senior Program Assistant EILEEN CHOFFNES, Senior Program Officer HEATHER COLVIN, Program Officer PATRICIA CUFF, Program Officer ALICIA GABLE, Senior Program Officer HELLEN GELBAND, Senior Program Officer AMY GIAMIS, Senior Program Assistant STACEY KNOBLER, Senior Program Officer KATHERINE OBERHOLTZER, Research Associate MICHELE ORZA, Scholar/Study Director ALYSON SCHWABER, Research Associate LAURA SIVITZ, Research Associate PENELOPE SMITH, Research Associate DIANNE STARE, Research Assistant KIMBERLY WEINGARTEN, Senior Program Assistant JULIE WILTSHIRE, Financial Associate

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: J. Lyle Bootman, Arizona Health Sciences Center, University of Arizona, Tucson, Arizona Larry Culpepper, Boston University Medical Center, Boston, Massachusetts John Idoko, Jos University Teaching Hospital, Jos, Nigeria Noddy Jinabhai, School of Family and Public Health, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa Peter Okaalet, MAP International, Nairobi, Kenya Jean W. Pape, Weill Medical College of Cornell University, New York Susan C. Scrimshaw, University of Illinois, Chicago, Illinois Deborah von Zinkernagel, Pangaea Global AIDS Foundation Suwit Wibulpolprasert, Ministry of Public Health, Thailand

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Paul A. Volberding, M.D., Professor and Vice-Chair, Department of Medicine, University of California, San Francisco; and Harold J. Fallon, M.D., Dean Emeritus, School of Medicine, University of Alabama at Birmingham. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Preface Today, 14,000 people will contract HIV, and another 8,500 will die from AIDS. Malaria and tuberculosis (TB) will each claim roughly 3,000 more lives. These same cruel events will take place tomorrow and the next day and next week and next month. The death toll will only spiral upward as the HIV epidemic continues its global spread. The terrible pandemic of HIV/AIDS has triggered an extraordinary response—a global counterattack mounted by international organizations, national governments, private philanthropies, pharmaceutical companies, churches, and individuals. The United Nations Global Fund, the World Health Organization’s 3 × 5 Initiative, The World Bank, the Bill and Melinda Gates Foundation, national foreign aid programs, numerous faith-based groups, corporations, and nongovernmental organizations are committing funds, medications, and personnel to the battle against HIV/AIDS. The U.S. government joined the battle in earnest when Congress enacted President George W. Bush’s Emergency Plan for AIDS Relief (PEPFAR) and earmarked $15 billion for the campaign. This broad range of global commitments has brought about a new era of possibility in preventing and treating HIV/AIDS and caring for those affected by the disease. The campaign against HIV/AIDS has no precedent. Smallpox was defeated by a globally coordinated search-and-destroy strategy requiring only a single patient encounter to deliver the vaccine. In contrast, the strategy of directly observed therapy that lies at the core of modern TB treatment necessitates daily patient contact over much of the treatment course and therefore a far larger health workforce. Fighting HIV/AIDS will require the daily delivery of medications and the clinical management of

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS patients for the rest of their lives. The sheer volume of health workers—and support systems—needed to wage this battle is well beyond anything before required of a public health campaign. The challenge is compounded by a chronic paucity of doctors, nurses, and other health personnel in many of the low-income countries targeted by PEPFAR where the epidemic is most fulminant. Sub-Saharan Africa, for instance, bears 25 percent of the world’s overall burden of disease and 60 percent of the world’s HIV/AIDS burden but has only 1.3 percent of the world’s health workforce. There is one physician for every 360 people in the United States as compared with one for every 30,000 in Mozambique; one nurse exists for every 125 people in the United States but only one for every 5,000 in Uganda. There are 11 pharmacists in Rwanda. Simply put, fighting HIV/AIDS in much of the world means building human health care capacity. No meaningful counterattack can occur without an adequate force of qualified health personnel to plan, implement, and sustain the campaign. In recognition of this fact, the PEPFAR legislation called for a pilot program to mobilize U.S. health professionals to work overseas in support of the plan’s mission. The Office of the U.S. Global AIDS Coordinator at the Department of State, in turn, asked the Institute of Medicine to convene a committee to conduct a rapid study of options for such a program and report its recommendations. Motivated by the urgency of the global need and the historic opportunity to contribute to public health policy, the committee carried out its change with intensity, speed, and a sense of mission. Healers Abroad is the product of that effort. Drawing on the extensive and varied experience of the committee members, testimony from health workers in the field, and the published literature on the global health workforce, the committee recommends programs in six key areas. Implementation of these recommendations would augment and accelerate the mobilization of U.S. health personnel to PEPFAR focus countries to help strengthen health care capacity and develop collaborative partnerships abroad. The committee also recommends that these programs be managed in a closely coordinated fashion as the Global Health Service. The resulting program would both symbolize the commitment of the people of the United States and catalyze the movement of U.S. health personnel overseas to help in the global counterattack on HIV/AIDS. It would be a program with a human face, combining the powerful tradition of people-to-people assistance with the best in contemporary health science and information technology. It would be a program of strategic humanitarianism, providing the support required by U.S. health professionals to assist people in need and to train counterpart health personnel abroad. The Global Health Service would help to stabilize societies at risk and demonstrate American compassion and civic spirit.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS It is the committee’s hope that this report will contribute to the success of PEPFAR and prove useful to others concerned with building a health workforce sufficient to meet the global HIV/AIDS challenge. It is our further hope that the report will be remembered as an early blueprint contributing to a new, enduring, and robust role for U.S. health professionals in improving global health. Fitzhugh Mullan Committee Chair

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Acknowledgments The committee recognizes the tremendous efforts of several individuals whose contributions invigorated discussions at its meetings and enhanced the quality of this report. For their expert advice, opinions, and willingness to assist, the committee thanks consultants Thomas Denny, Bjorg Palsdottir, and Kai Spratt, and its Board on Global Health liaison, Richard Guerrant. Special appreciation goes to writer and senior consultant Claire Panosian, whose skill in transforming ideas into words was instrumental in articulating the spirit of the committee’s work. The committee also acknowledges with great thanks the testimony of Barbara Stilwell, Ummuro Adano, James Heiby, Gilbert Kombe, Antoine Augustin, Eric Krakauer, King Holmes, Col. Maureen Coleman, Gail Reed, Paul Dirdak, Ky Luu, Brian Palmer, Elise Frederick, Karen Hein, Ronald Campbell, Mike St. Louis, Thurma McCann Goldman, Don Weaver, Jack Hawkins, Nancy Kelly, Holly Burkhalter, Eric Friedman, Fred Valentine, Robert Einterz, Michael Scheld, Daniel Wikler, John Shippee, James Smith, Xingzhu Liu, Holly Ladd, and Rebecca Riccio. Additional thanks go to Stephen Moore, Annalisa Trama, Paul Moffat, Lydia Mungherera, and Chuka Anude for their written testimony from the field. Special recognition goes to Michael St. Louis, Estelle Quain, and Michele Moloney-Kitts for their extra effort and repeated attention to the ongoing provision of information and support for the study. Joseph O’Neill, M.D., M.S., M.P.H., and Mark Dybul, M.D., of the Office of the U.S. Global AIDS Coordinator deserve particular recognition for generously supporting the vision that U.S. health professionals can make a difference in the fight against the global HIV/AIDS pandemic. The committee would be remiss if it did not also acknowledge the hard

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS work and dedication of the study staff from the Board on Global Health. Patrick Kelley, the director of the board, was an extremely valuable resource with his extensive knowledge of overseas placement of health professionals. We would also like to thank Patricia Cuff, study director, for her energy and commitment to ensuring that the report would be of the highest possible quality given the intense time pressure to complete the project. To Alyson Schwaber, research associate, the committee extends its utmost gratitude for her outstanding ability to examine critically and understand the research on overseas placement of health professionals. Dianne Stare did a remarkable job as research assistant, and Allison Berger performed equally well coordinating many of the study logistics. Final thanks are expressed to our editorial consultant Rona Briere and her steadfast assistant, Alisa Decatur.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Contents     EXECUTIVE SUMMARY   1      THE HUMAN RESOURCE CRISIS IN GLOBAL HEALTH     1   INTRODUCTION   19 2   CONFRONTING HIV/AIDS ON THE GROUND   44 3   NEW ROUTES OF ENGAGEMENT AGAINST GLOBAL HIV/AIDS   68      AMERICANS RESPONDING TO THE CRISIS     4   ENVISIONING A U.S. GLOBAL HEALTH SERVICE   86 5   PROGRAMS OF THE U.S. GLOBAL HEALTH SERVICE   96      Global Health Service Corps,   98      Health Workforce Needs Assessment,   107      Fellowship Program,   111      Loan Repayment Program,   117      Twinning Program,   120      Clearinghouse,   126 6   LOOKING AHEAD   138

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS     APPENDIXES     A   Information Gathering Workshop Agendas   151 B   Ethical Issues in Foreign Health Workforce Assistance Programs   157 C   Assessing the Human Resource Need for Expanding HIV/AIDS Services in the 15 PEPFAR Focus Countries   164 D   U.S. Organizational Experience with Volunteer Health Programs   180 E   E-Health and the HIV/AIDS Epidemic: Using Technology to Support U.S. Workforce Expansion and Local Capacity Building in PEPFAR Nations   195 F   ICT Considerations to Support PEPFAR Activities   214 G   Attributes of Governmental and Nongovernmental Organizational Models for the Potential Administration of the Global Health Service   225 H   Biographies   231

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Tables, Figures, and Boxes TABLES 1-1   Health Care Providers (per 100,000 Population) in Selected PEPFAR Countries,   35 1-2   Health Care Providers (per 100,000 Population) in the United States,   35 1-3   Deficit or Surplus of Doctors, Nurses, and Midwives,   36 2-1   Available Evidence on Biological and Disease-Related Vulnerability Factors,   46 3-1   Estimated Number of People Receiving and Needing ART, and Percent Coverage in Developing and Transitional Countries by Region, December 2004,   74 5-1   Six Proposed Programs of the U.S. Global Health Service,   97 5-2   Workforce Needs Assessments for PEPFAR Focus Countries,   110 5-3   Advantages and Disadvantages of Short- and Long-Term Exchanges,   122 5-4   Advantages and Disadvantages of Partnership Management Models,   125 5-5   A Sampling of Organizations Providing Information about HIV/ AIDS Work Abroad,   130 6-1   Potential Partners Addressing HIV/AIDS,   142

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS C-1   Basic HIV/AIDS Indices and Human Resource Status in the 15 PEPFAR Focus Countries,   166 C-2   Current and Projected Human Resource Stock in the 15 PEPFAR Focus Countries,   169 C-3   Estimated Total of Key Health Workers Needed to Deliver Health Services in the 15 PEPFAR Focus Countries,   170 C-4   Estimated Need for Master Trainers in the 15 PEPFAR Focus Countries,   176 C-5   Sensitivity Analysis of Human Resource Gap in the 15 PEPFAR Focus Countries in 2009,   176 D-1   Organizations by Category,   181 D-2   Cross-Cultural Training,   193 E-1   Nurses, Midwives, and Physicians per 100,000 Population,   197 E-2   Technologies and Related Tools Associated with E-Health in Low-Resource Environments,   201 E-3   Comparative Bandwidth Costs: United States, Uganda, and Nigeria,   202 E-4   E-Health Options,   207 G-1   Governmental Organizational Models,   226 G-2   Nongovernmental Organizational Models,   229 FIGURES 1-1   Regional disparities in medical schools and graduates,   30 1-2   More health workers, fewer deaths,   33 1-3   Percentage of foreign-trained doctors in selected developed countries,   38 C-1   Human resource gap for doctors, nurses (including midwives), and pharmacists,   174 BOXES 1-1   The Triple Impact of HIV/AIDS on Health Workers,   28 1-2   Reversing the Brain Drain: TOKTEN in Vietnam,   39 1-3   Report Organization,   40 2-1   The World Health Organization’s Strategy for Comprehensive Chronic Disease Care in the Developing World,   61

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS 3-1   The Four Cornerstones of PEPFAR,   70 3-2   Community Health Workers: Augmenting Care for HIV/AIDS and Tuberculosis in Haiti,   75 3-3   Pfizer Fellows,   82 5-1   The Intergovernmental Personnel Act,   101 6-1   International Health and Medical Education Consortium,   146 C-1   Categorization of Countries According to the Level of Prevalence and Doctors’ Gap,   175

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