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4
Invest in People, Institutions, and
Capacity Building with Global Partners
While the United States can offer low- and middle-income countries par-
tial solutions to help resolve the challenges they face in delivering basic health
services, these countries require capable local leaders, managers, analysts, and
researchers to identify solutions that work and are sustainable in their own
countries. Capacity building efforts that help produce a critical mass of leaders,
researchers, practitioners, and educators; create an enabling institutional environ-
ment through improved infrastructure and professional support; and fund a steady
stream of diverse grants to sustain the efforts of researchers would benefit health
in low- and middle-income countries and begin to address the severe deficits in
their health sector workforce.
LONG-TERM INSTITUTIONAL CAPACITY BUILDING
Much of the international community’s work in building the capacity of
public health practitioners and researchers in low- and middle-income countries
has borne noticeable results. Once dominated by health experts from advanced
economies, the field of public health now reflects a more diverse and globally
representative group of experts and organizations. Twenty-five years ago, global
health experts gave guidance to health officials in low-income countries; today,
the relationship is more a partnership than a tutorial. Low- and middle-income
countries have health experts of their own who not only occupy a seat at the same
table, but are often better informed about the health status and specific needs of
their country or region than their international partners.
U.S. government agencies, such as the National Institutes of Health (NIH)
and the Centers for Disease Control and Prevention (CDC), have long-standing
0
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0 THE U.S. COMMITMENT TO GLOBAL HEALTH
capacity building programs aimed directly at strengthening researchers and pub -
lic health practitioners in low- and middle-income countries (see Box 4-1).
Universities, pharmaceutical companies, and more recently, public-private prod -
uct development partnerships (PDPs) have trained the workforces of low- and
middle-income countries in good research, laboratory, and clinical practices as
a secondary outcome of their clinical trial work. While such efforts have helped
to provide trained health workers and researchers, a lack of institutional support
within these countries has often driven away the most promising and well-trained
practitioners and researchers.
While many existing and new global institutions have received increased
funding, research institutions in low- and middle-income countries (such as
universities, public health schools, science academies, and research centers)
BOX 4-1
Building Capacity of Researchers: The Role of
U.S. Federal Executive Branch Agencies
U.S. government agencies have successfully contributed to building the capac-
ity of international partners in health research. Two noteworthy efforts are those of
the NIH’s Fogarty International Center and the CDC’s Field Epidemiology Training
Program.
NIH’s Fogarty International Center
The Fogarty International Center (FIC) at NIH runs a highly successful AIDS
International Training and Research Program (AITRP) that brings scientists from
low- and middle-income countries to the United States to train in multidisciplinary
biomedical and behavioral research in HIV/AIDS and the related epidemic of
tuberculosis in their countries.
AITRP trainees are sponsored for a master’s or doctorate degree or hold
postdoctoral positions. The program uses several scientific, political, and economic
strategies to encourage scientists to return to their home countries after training.
By focusing on research that is responsive to priorities in the home country—and
maximizing the amount of training conducted there—trainees are better equipped
to find jobs or funding in their home countries once training is complete. A trainee
may be allowed to retain an e-mail address and access to journals through the
U.S. host institution even after training. Trainees come to the United States under
nonimmigrant temporary visas; some sign agreements that require them to reim-
burse their training costs if they do not return to their home country (Kupfer et al.,
2004).
A 2002 survey of five of AITRP’s longest-funded programs showed an average
return rate of 80 percent among their 186 long-term trainees (Kupfer et al., 2004).
An evaluation of the entire program this past year showed an 85 percent rate of
return among trainees over 15 years (Kupfer, 2009). FIC recently built on the
AITRP model and designed the Millennium Promise Awards to extend research
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INVEST IN PEOPLE, INSTITUTIONS, AND CAPACITY BUILDING
have not experienced commensurate growth or been sufficiently engaged in the
global health arena. In the United States, academia, nonprofit organizations, and
commercial entities play an important advisory role in domestic U.S. healthcare
policy, but in resource-limited nations, indigenous scientific expertise is rarely
sought when shaping national policies. As a result, research institutions in these
countries are often neglected and bypassed as working partners by many external
donors.
Yet the challenges faced by these nations in delivering quality and equitable
health services require capable leaders, managers, analysts, practitioners, and
researchers to identify problems and solutions that can influence public health
policy. Many low-income countries have neither a critical mass of researchers
and health workers nor sufficiently funded institutions to conduct the research
capacity to cancer, cerebrovascular disease, lung disease, obesity, lifestyle fac-
tors, and genetics as related to chronic diseases (FIC, 2008).
CDC’s Field Epidemiology Training Programs
The Field Epidemiology Training Program (FETP) and the Field Epidemiology
and Laboratory Training Program, which offers an added laboratory component,
are applied epidemiology programs offered by the CDC’s Division of Global Public
Health Capacity Development (DGPHCD). Both programs help countries develop
and implement dynamic public health strategies to improve their health systems
and infrastructure.
An in-country resident adviser is assigned to provide training and technical
assistance for four to six years. The curriculum of both two-year programs is
modeled on CDC’s Epidemic Intelligence Service, typically involving classroom
instruction (25 percent) and field assignments (75 percent). In class, trainees take
courses in epidemiology, communications, economics, and management, while
learning quantitative and behavior-based strategies. In the field, trainees conduct
epidemiologic investigations and field surveys, evaluate surveillance systems,
perform disease control and prevention measures, report their findings to decision
makers, and train other health workers.
Since 1980, DGPHCD has helped to establish 30 field epidemiology training
programs that have produced more than 1,000 graduates. In 2008, the programs
had 276 active trainees; together, trainees and graduates conducted more than
300 outbreak investigations and gave 280 presentations at international confer-
ences. As of April 2009, 17 resident advisers for epidemiology and laboratory were
supporting 12 programs in Central America, Asia, the Middle East, and Africa.
Located at CDC’s headquarters in Atlanta, Georgia, DGPHCD staff provide addi-
tional scientific support and advice to sustain FETPs and related programs around
the globe. This division of CDC also supports the technical components of five
other mature programs in Brazil, Egypt, Jordan, Saudi Arabia, and Thailand. Plans
for the establishment of new programs are under way in 14 countries, including
Afghanistan, Central Africa, Iraq, and Yemen (CDC, 2008).
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and analytical work needed to find solutions (not to mention inform policy) to
address the health problems endemic to their countries.
For example, universities in low-income countries—vital to human resource
development—often face a host of problems. They suffer from lack of funds,
weak infrastructure, outdated or misaligned training programs, overcrowded
classrooms, and overburdened and underpaid staff (Dovlo, 2003; Tettey, 2006).
In recent years, many health science schools in sub-Saharan Africa have been
asked to double or even quadruple the number of students without concomitant
increases in their budgets and despite significant staff vacancies (Effah, 2003;
Houenou and Houenou-Agbo, 2003; Jibril, 2003; Taché et al., 2008). For stu -
dents, the shortage of teachers means a lack of mentorship and academic support.
Students often graduate without being equipped to address critical tasks pertinent
to the burden of disease and epidemiologic scenarios for which their service is
needed (Taché et al., 2008). Health practitioners are often unprepared to deal with
the challenges of working in underresourced clinics and hospitals (WHO, 2006).
Both researchers and faculty struggle to find resources for substantive research
projects. The consequent overall lack of opportunity and career advancement
results in low morale, providing little incentive to work in academia or the public
sector or to remain in the country.
The committee finds that strengthening universities, research centers, and
government institutes in low- and middle-income countries could have a direct
impact on the ability of these countries to muster the internal resources needed to
address their own health problems. In particular, the committee finds that by sup -
porting these institutions, the United States can help to develop an environment of
inquiry, entrepreneurship, and experimentation that brings together researchers,
practitioners, and policy makers, across disciplines and borders, to solve some of
the pressing health problems facing less wealthy nations.
Expand Commitment to Institutional Capacity Building
The United States still has much to contribute in building academic and
research capacity in low- and middle-income countries, given its expertise in
research, science, and technology. A global health field has recently emerged that
has been defined as an area for study, research, and practice that places a priority
on improving health and achieving equity in health for all people worldwide. The
global health field emphasizes transnational health issues, determinants, and solu-
tions; involves many disciplines within and beyond the health sciences; promotes
interdisciplinary collaboration; and is a synthesis of population-based prevention
and individual-level clinical care (Koplan et al., 2009). By building on success -
ful programs and leveraging the growing involvement of U.S.-based universities,
commercial entities, and foundations in global health, the United States has an
opportunity to help redress the neglect of universities and other research and
public health institutions in resource-limited settings.
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Unprecedented energy and enthusiasm for global health now exist among
students and medical residents in U.S. universities (Drain et al., 2007). U.S.
academic institutions have a vast untapped potential to work with academic insti -
tutions in low- and middle-income countries to advance the academic environ -
ment in both sets of institutions by strengthening faculty and improving training
programs and curriculums. Many examples in the past several years also illustrate
the interest in the commercial sector and among professional associations in shar-
ing their business and technical acumen for the greater social good.
Several U.S.-based foundations, such as Rockefeller, Carnegie, and Pew,
were some of the first organizations to embark on capacity strengthening pro -
grams in low- and middle-income countries. For example, the Rockefeller Foun -
dation—which contributed $25 million in 1921 (equivalent to $357 million
today) to establish 21 schools of public health in cities such as London, Tokyo,
Calcutta, and Sao Paulo—today continues to support many institutions and fel-
lowship programs for health scientists worldwide (Fosdick, 1989).
U.S. philanthropies and the U.S. government should continue the tradition of
funding capacity building initiatives and expand this commitment to leverage the
growing interest of academia, nonprofit organizations, and commercial entities.
With increased support, research institutes could adopt innovative methods and
technologies for distance learning and collaboration and, thus, help to reshape
education and research in global health.
Support Long-Term and Mutually Advantageous Institutional Partnerships
The committee finds that the United States can support institutional capac -
ity building in low- and middle-income countries by funding and participat -
ing in long-term and mutually advantageous institutional partnership compacts.
Through sustained partnerships, U.S. government agencies, universities, corpo -
rate entities, and foundations can strengthen the local capacity of researchers,
practitioners, and policy makers, as well as their respective institutions, in low-
and middle-income countries.
Many examples of capacity building partnerships among institutions exist,
with different arrangements and varying benefits for participants. Traditionally,
these partnerships have involved an institution from a high-income country and
an institution from a low- or middle-income country (sometimes referred to as
“twinning”), but increasingly, the partnerships involve partners from low- and
middle-income countries only. For example, under the leadership of the Mexican
government, the Mesoamerican Public Health Institute was established to support
a virtual network of academic and research institutes in the Central American
region (López, 2008). Both models have their advantages; in a partnership involv-
ing high-income countries, the high-income institution brings valuable expertise
to the table but can overshadow the other partner, while a partnership between
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THE U.S. COMMITMENT TO GLOBAL HEALTH
low- and middle-income institutions tends to be more equitable and less costly
but offers fewer opportunities to transfer expertise.
Given the importance of the emerging economies, another type of partner-
ship called “triangulation” has been suggested to leverage the strengths of insti -
tutions from all three levels of economies: high, middle, and low income. The
United States might, for example, establish a partnership with both Brazil and
Mozambique. The International Association of National Public Health Institutes
(IANPHI) is exploring this exact partnership, among others, in an attempt to build
the capacity of public health institutes globally (see Box 4-2).
Such partnerships often result in the establishment of Centers of Expertise
that serve entire regions. Centers of Expertise are promising, especially in the
initial stages of capacity building, because they afford some coordination among
multiple, differentiated institutions, which can help to propel and sustain entire
professional fields.
BOX 4-2
National Public Health Institutes: Integrating Vertical
Programs and Enhancing Public Health Capacity
National Public Health Institutes (NPHIs) are science-based governmental
organizations, such as the CDC in the United States, FIOCRUZ in Brazil, RIVM
in the Netherlands, and CDC in China, that provide expertise and leadership for
core public health functions, including research, disease surveillance, outbreak
investigation, laboratory science, policy formulation, and health education and
promotion.
Coordinating core public health functions through an NPHI can result in a more
efficient use of resources, improved delivery of public health services, and in-
creased capacity to respond decisively to public health threats and opportunities.
NPHIs are particularly beneficial in low-resource countries, where they provide
public health professionals with a group of technically oriented colleagues and a
prestigious career path, helping to stem the tide of experts leaving government
service for higher-paying jobs with international nongovernmental organizations.
NPHIs in low-resource countries also encourage governments to set science-
based public health priorities and policies, better integrate and leverage funds
from numerous vertical programs, and plan strategically and systematically for
future human resource and infrastructure needs.
NPHIs vary in scope, function, and size along a continuum from fledgling insti-
tutes to organizations with comprehensive responsibility for research, programs,
and policy for almost all public health threats. Most NPHIs, including the U.S.
CDC, began as very focused public health or research institutes charged with
identifying and combating infectious disease threats. Over time, CDC and many
other NPHIs in mid- to higher-resource countries have evolved and expanded to
meet new public health challenges, including death and disability from chronic
diseases, environmental and occupational threats, and injury prevention. The
growth of NPHIs over the years—including their successes and failures—provides
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INVEST IN PEOPLE, INSTITUTIONS, AND CAPACITY BUILDING
The committee finds that partnerships among institutions in advanced and
emerging economies and resource-limited nations are a promising practice and
should be expanded. Institutional partnerships—whether twinning, triangulation,
or establishing Centers of Expertise—have proved an effective way to build
capacity when they are conceived as a long-term commitment and based on an
equitable relationship among participants. Numerous institutions in low- and
middle-income countries have been able to take advantage of long-term partner-
ships to build their institutional capacity. Makerere University in Uganda is an
example of an institution that has leveraged multiple partnership compacts with
universities, commercial industry, foundations, and PDPs to reestablish the uni -
versity as a leading institution in sub-Saharan Africa (see Box 4-3).
Although there has been little rigorous evaluation to parse the most promis -
ing aspects of the institutional partnership model, some lessons can already be
an important frame of reference for those with more limited current capacity as
they consider how to move forward. Such a “road map” is invaluable not only to
lower-resource economies, but also to countries such as the United Kingdom,
Hong Kong, and Canada, which have created NPHIs only recently in response to
public health challenges such as bovine spongiform encephalitis and severe acute
respiratory syndrome.
Moving NPHIs forward along the continuum toward more technical depth and
comprehensive capacity is the primary goal of the International Association of
National Public Health Institutes, which serves as a professional organization
for NPHI directors, assisting them in their professional and institutional growth
through scientific meetings, leadership development activities, and seed grants
for research and training. IANPHI’s fundamental philosophy is that the collective
history, knowledge, and scientific expertise of its member institutes is a powerful
force for transforming public health systems in low-resource countries.
IANPHI is collaborating with nine low-resource countries to create new NPHIs
or to substantially increase capacity at fledgling institutes. IANPHI’s nine long-term
NPHI development sites include Burkina Faso, Ethiopia, Guinea Bissau, Mozam-
bique, and Tanzania, with projects being explored in Bangladesh, Cambodia, Cen-
tral America, and Ghana. In addition to its strategic investments of up to $670,000
in each of the nine long-term project sites, IANPHI leverages substantial strategic
planning and organizational design expertise, scientific technical assistance, and
public health training for each project from other IANPHI members. For example,
Guinea Bissau received technical assistance and training from Brazil; Finland
is providing technical assistance and training to Tanzania; the Netherlands and
Norway have committed to providing assistance to Ethiopia; and Morocco has
pledged technical assistance and training to Burkina Faso. In addition, IANPHI
links into each project the specialized expertise of other partners, including WHO,
and links with key funders and programs, including the Health Metrics Network,
the Global Fund, bilateral aid groups, and the U.S. government.
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BOX 4-3
Rebuilding Uganda’s Makerere University
Through Institutional Partnerships
Makerere University, established in 1922, is one of Africa’s oldest universities.
It has 30,000 undergraduate and 3,000 postgraduate students. Through interna-
tional collaborations with a number of institutions, Makerere has established itself
as a global center for research, especially on HIV-related health outcomes. Once
reputed as the preeminent research institution in sub-Saharan Africa, Makerere
University faced financial and institutional collapse during the late 1980s. The re-
structuring of administration, increases in enrollment, and a reallocation of private
funding have been instrumental in rebuilding Makerere University as an example
for surrounding institutions suffering similar infrastructure collapse (Task Force on
Higher Education and Society, 2008).
Among the university’s more notable collaborations has been its partnership
with Johns Hopkins University in the United States to establish a College of Health
Sciences. A two-year initial phase includes a needs assessment plan written by
students and led by Makerere faculty members with support from Johns Hopkins,
building on a long history of Johns Hopkins’ collaboration with Makerere Univer-
sity. The plan will include an evaluation of how Makerere University might most
effectively promote local health initiatives involving HIV; test innovative strategies
such as voucher systems; and support implementation of health programs based
on research—for example, the Makerere University finding that circumcision can
reduce the risk of acquiring an HIV infection by 48 percent. Over the next eight
years, a strategic plan will be implemented jointly by an advisory panel (made up
of deans from Makerere’s College of Health Sciences and Johns Hopkins faculty)
and an advisory council drawn from Ugandan government and civil society. After
identifying Uganda’s health needs and drawing up a plan to meet them, Makerere
University will expand its capacity to improve health outcomes in Uganda and East
Africa (Gebel, 2009).
In another successful collaboration, Makerere University partnered with Pfizer
Inc., Accordia Global Health Foundation, and the Academic Alliance to establish
the Infectious Diseases Institute (IDI) in 2004. African-owned and African-led,
IDI is now a preeminent center for infectious disease research, training, and
treatment. By enhancing the stature and recognition of the Faculty of Medicine
at Makerere University, IDI is helping to reverse the trend of African healthcare
professionals’ pursuing career opportunities abroad. The IDI model has proven ex-
traordinarily productive, with far-reaching applications for similar disease-fighting
efforts elsewhere in Africa (Accordia Global Health Foundation, 2009a).
Another collaborative effort by Makerere University, the IDI-based Sewankambo
Scholarship Program, aims to build the next generation of academic medical
r
esearchers in Africa. The program couples outstanding African clinicians with
at least one internationally recognized investigator who commits to providing
five years of substantive, ongoing mentorship in a rigorous research program.
D
uring this process, scholars also develop their own research teams and mentor,
in turn, another generation of young Ugandan investigators, thus expanding “in-
c
ountry” clinical and applied research with little assistance from Western institutions
(
Accordia Global Health Foundation, 2009b).
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learned from partnerships undertaken in health and other fields such as agriculture
and science. Institutional partnerships should do the following:
• Represent a long-term financial commitment (5 to 10 years or more) with
a focus on sustainability and creating self-reliance (Crisp et al., 2000;
Drain et al., 2007; ODI, 2009).
• Be based on trust, ethical principles, transparency, and equity in exchange
and ownership, where all partners find the relationship mutually advanta -
geous and respect and understand differences in cultures and perspectives
(Jones and Blunt, 1999; KFPE, 1998; Ofstad, 1999; Tsibani, 2005).
• Have leadership commitment from their respective Ministries of Health
and Higher Education (among others) (Crisp et al., 2008; Nuyens,
2007).
• Focus on strengthening the institution and not a particular individual,
paying attention to the crucial need for improving the institutional envi-
ronment to enable problem solving and policy engagement.
• Incorporate an interdisciplinary approach that goes beyond the medical
and health science schools and includes disciplines such as public health
and policy, business, engineering, agriculture, and economics.
• Define goals and metrics of success at the beginning of the partnership;
all parties involved must commit to evaluate the model and remain flex-
ible to adjust as needed (Crisp et al., 2000; Ijsselmuiden et al., 2004;
KFPE, 1998; ODI, 2009).
• Reach agreement at the start regarding the ownership of data, specimens,
and intellectual property, as well as how information should be shared,
given the existing information-sharing infrastructure.
While institutional partnerships should be flexible in order to build upon the
strengths of their participants, they should endeavor to engage in the following
five important and focused activities:
1. Invest in training to help build a critical mass of researchers, practitio-
ners, and educators. Institutional partnerships should play an explicit role in
helping to educate and train leaders, researchers, teaching faculty, health workers,
and professionals (such as managers, public health practitioners, and policy ana -
lysts). Training must be based on a comprehensive approach to build long-term,
sustainable, and independent leadership, research, and teaching capacity and
should include investment in master’s and doctoral training programs (Maziak
et al., 2004; Nchinda, 2002). Adequately staffed universities, health science
schools, and teaching hospitals will go a long way toward training leaders and
managers while addressing the critical shortage in the health workforce (Crisp
et al., 2008).
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THE U.S. COMMITMENT TO GLOBAL HEALTH
2. Create an enabling institutional environment to rectify a development
paradox. Better training can lead to a depleted workforce if trained workers emi -
grate (Arah et al., 2008). Significant and long-term investments will be required
to rectify the “push” factors that drive the health workforce out of underserved
areas and discourage professionals from serving the public good. Investments in
infrastructure (such as properly equipped labs and increased access to research
tools and scientific journals) and professional support will help retain trained
health workers among underserved populations (Dovlo, 2004). Examples of such
support are compensating professionals for mentoring activities and providing
opportunities for their career advancement through faculty development and
exchange programs.
3. Fund a steady stream of diverse grants to sustain the efforts of research-
ers. To further support and sustain institutions, institutional partnerships should
work to ensure a steady stream of grants to generate and share knowledge that
can inform health policy. Grants could be directed to underfunded research areas,
such as health systems research, and focus on critical needs such as improving
the delivery of existing interventions.
4. Generate demand for scientific and analytical work to influence public
policy. Once best practices are identified in relevant health areas by institutional
partnerships, country leaders can take up the task of bridging the knowledge-
action gap in their societies and create evidence-based guidelines to inform
good practice for health workers, policy makers, leaders, professionals, and
academicians.
5. Build credibility by contributing to real and immediate health policy
challenges. By contributing to solving some of the most pressing global health
challenges through a specific focus on, for example, human resource capacity
issues, partnerships can have a meaningful and real-time effect on the ongoing
delivery of care within a particular country or region. This will enhance the
credibility of the local institution, both with local policy makers and with exter-
nal donors who may be skeptical of the benefits of long-term capacity building
investments, and offer opportunities to partner with service delivery programs
such as the President’s Emergency Plan for AIDS Relief or President’s Malaria
Initiative.
Recommendation 4-1. Federal executive branch agencies, along with U.S.
private institutions, universities, nongovernmental organizations, and com -
mercial entities, should provide financial support and engage in long-term
and mutually advantageous partnerships with institutions—universities,
public health and research institutes, and healthcare systems—in low- and
middle-income countries with the goal of improving institutional capacity.
These partnerships should enable local and global problem solving and
policy engagement by
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• Investing in training,
• Creating an enabling institutional environment,
• Funding a steady stream of diverse research grants,
• Generating demand for scientific and analytical work that influences
public policy, and
• Contributing to the control of real and immediate health problems.
RECTIFY THE HEALTH WORKFORCE CRISIS
Many countries face critical health workforce deficits that directly affect
health outcomes. National health resource strategies that go beyond simply
increasing the number of health workers and endeavor to understand and improve
the dynamics of the labor market have been successful in stemming the tide of
workforce migration and in recruiting and retaining labor for underserved areas.
While such strategies require commitments by governments to construct and
finance human resource plans, the international community, too, needs to play an
important role in supporting and financing these country-led plans.
Global Health Workforce Deficits Are of Crisis Proportions
Human resources are critical to improving global health. The density and
quality of the health sector workforce directly affects health outcomes, with
increased density being associated with reductions in maternal, infant, and under-
5 child mortality (Anand and Barnighausen, 2007; Chen et al., 2004). On average,
countries with fewer than 2.5 healthcare professionals (counting doctors, nurses,
and midwives) per 1,000 people failed to achieve an 80 percent coverage rate for
measles immunization or for deliveries by skilled birth attendants (Chen et al.,
2004).
Such statistics have led the World Health Organization (WHO) to recommend
that a country maintain a health workforce density of no less than 2.28 workers
per 1,000 population (or 1 health worker for every 400 people) to achieve desired
levels of key health intervention coverage (WHO, 2006). Based on this measure,
the world has a global shortage of 2.4 million doctors, nurses, and midwives;
when other health service providers such as medical technicians are included, the
global shortage reaches 4.3 million health workers (WHO, 2006).
WHO estimates that 57 countries (36 of which are in sub-Saharan Africa)
have critical health workforce shortages, making it difficult (if not impossible)
for them to achieve the health-related Millennium Development Goals (MDGs)
(WHO, 2006). For example, sub-Saharan Africa would need to increase its health
workforce by 140 percent to support attainment of the MDGs (UN, 2008). A
study to assess the human resources required to achieve the MDGs in Tanzania
and Chad found that by 2015, Tanzania would require 98,000 full-time health
workers, but would have only 36,000; in Chad the situation would be even worse,
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BOX 4-4
Health Sector Human Resource Strategies
to Address the Workforce Crisis
Workforce policies focused on simply increasing the number of health workers
to address health needs (without understanding the dynamics of the labor market,
such as supply and demand) often fail to achieve their objectives (Glassman
et al., 2008; Vujicic and Zurn, 2006). Policies that incorporate more explicitly the
behavior of those who supply labor (doctors, nurses, midwives, and other provid-
ers) and those who demand labor (local governments, the private sector, and
foreign governments) and endeavor to understand how each group responds to
incentives can be successful (Vujicic and Zurn, 2006).
The supply of healthcare professionals at the country level can be thought of
as the number of individuals with the necessary qualifications who are willing to
work in the healthcare sector. Supply is influenced by opportunities to migrate,
as well as access to training, labor conditions, and wages. By understanding how
these factors influence the supply of viable healthcare professionals, countries
can create public policies to address their health workforce shortages (Vujicic and
Zurn, 2006).
Given that resources are limited, what is desirable or needed is not always
feasible. Thus, the demand for healthcare services—the quantity of healthcare
services that individuals or governments are willing to pay for—does not always
correspond to healthcare needs. For example, in many cases, hospitals need
more doctors and nurses to achieve the desired level of health service delivery,
but do not have the resources to pay their wages and thus do not demand more
healthcare providers. Other factors, such as the length of time required to educate
physicians, can delay changes in the available supply, thus delaying balance in
the labor market (Zurn et al., 2004).
Providing Educational Incentives
Targeted subsidies, grants, and scholarships are examples of incentives that
can be used not only to attract more students, but also to retain students who are
more likely to remain in the country and work in underserved areas (Marchal and
Kegels, 2003). Thailand provides an example of such incentive-based placement
of doctors to address urban and rural healthcare disparities (Wibulpolprasert and
Pengpaibon, 2003). Another measure to retain health workers could be to identify,
2005; McCoy et al., 2008). Another study has found that in several countries the
Global Fund has contributed to an exodus of employees from health ministries
by paying higher salaries than the government (Drager et al., 2006). While wage
discrepancies between locally financed positions and internationally financed
positions exist and may be especially problematic in areas that receive significant
international funding for programs such as HIV/AIDS (Shiffman, 2008), the
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at the time of entry to health worker education, those candidates who are likely to
stay in their country and work where they are most needed (Marchal and Kegels,
2003). A Ugandan study of nursing students found that those wanting to emigrate
would be least likely to work in rural areas (Nguyen et al., 2008). Governments
could then create incentives to target the students who do not aspire to migrate
as being the most inclined to work in rural and underserved areas.
Improving Working Conditions
Wage increases, additional benefits, and flexibility in working hours are other
examples of commonly used incentives to attract or retain workers. Yet recruiting
and retaining health staff requires an overall conducive environment that offers op-
portunities and favorable working conditions. Health personnel working in under-
served areas require special incentives that go beyond educational incentives and
reasonable salaries, such as hardship and transportation allowances; subsidized
school fees for children and housing; and opportunities for continued education
and career development. Reducing the brain drain within countries among doc-
tors requires “clear-cut, merit-based career structures that offer attractive posts
in clinical or research fields, accompanied by adequate remuneration” (Marchal
and Kegels, 2003).
Reforming the Skill Mix
In some instances, resource-limited countries are making greater use of mid-
level health workers, such as assistant medical officers, clinical officers, and surgi-
cal technicians (Heller and Mills, 2002; Marchal and Kegels, 2003). These workers
supplement the work of doctors and nurses to provide medical, obstetrical, and
surgical care in underserved areas. Midlevel workers can provide quality care if
appropriately trained, monitored, and given the opportunity to attend continuous
skill improvement courses (Dovlo, 2003; Vaz et al., 1999).
Overall, such incentives and policies can bring more workers into the public
health system and improve its effectiveness. National policies that improve labor
conditions by offering a mix of these incentives have been successful, but they
require a commitment by governments to formulate health resource plans. These
plans should be led by countries because the policies to address the local labor
market must be planned, implemented, and owned within national settings (Chen
et al., 2004).
evidence in this area is still sparse and requires further evaluation to understand
how international nongovernmental organizations and donor programming affect
the health sector labor market. Donors should be cognizant of the potential effect
their efforts to recruit health workers and professionals may have on local public
health recruitment efforts.
The demand for health workers in the United States and other advanced
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THE U.S. COMMITMENT TO GLOBAL HEALTH
economies is also a factor that can contribute to the recruitment of health work -
ers away from underserved areas in low- and middle-income countries. Trends
over the last 25 years show that the number and percentage of foreign-trained
nurses and doctors have increased significantly in most high-income countries
(Dumont, 2007). For example, nurse immigration to the United States has tripled
since 1994 to almost 15,000 entrants annually. In 2007, about 8 percent of all
registered nurses were estimated to be foreign educated; of these, 80 percent were
from lower-income countries (Aiken, 2007).
This has prompted many organizations to call for increased measures both to
limit the recruitment of healthcare professionals from other countries, especially
from countries most affected by human resource shortages, and to reduce U.S.
dependency on an immigrant workforce in the health sector. An examination of
U.S. migration, workforce, and training policies was not within the purview of
the committee’s charge.
The committee did consider the effect of migration of health workers on
health outcomes in low- and middle-income countries and finds that global
migration is not the main cause of the human resource crisis, nor would its
reduction be the main solution, even though it does exacerbate the acuteness of
the problem in some countries. Attempts to merely increase the supply of work -
ers by restricting emigration visas or reversing migration might have a modest
effect on the human resource crisis, but would not solve the problem and would
put unnecessary restrictions on the right of workers to migrate. For example,
the need for human resources in low-income countries, as estimated by WHO,
largely outstrips the number of immigrant health workers in the United States and
elsewhere (Dumont, 2007).
Moreover, at least one study examining the emigration of African physicians
and nurses found no evidence that migration substantially affected the 11 indi -
cators of mass primary care availability and public health outcomes (Clemens,
2007). If physicians or nurses abroad substantially degrade basic public health
conditions, one would expect to see a positive correlation between the number
of physicians abroad and childhood mortality. Yet the study found the exact
opposite. Countries with higher migration tend to have lower mortality rates.
Another analysis found similar results; higher physician migration density was
significantly associated with relatively “higher wealth and less poverty, higher
health spending, better development, and higher population health status” (Arah
et al., 2008).
Therefore, the committee finds that while migration is a highly visible and
volatile topic, it is a sign that even as a country is training internationally valuable
resources, it is not providing enough incentives to prevent these resources from
finding more promising opportunities elsewhere. Migration is a symptom of more
serious issues of chronic lack of reinvestment in the health workforce and health
systems of low- and middle-income countries that encourage workers to migrate
to wealthier countries. Addressing the human resource crisis in the health sector
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INVEST IN PEOPLE, INSTITUTIONS, AND CAPACITY BUILDING
will require reversing deficits in capacity, infrastructure, and leadership within
the health sectors of resource-limited countries.
Support Country-Led Health Sector Workforce Plans
The committee also finds that while low-income countries are the owners and
drivers behind national strategic plans to improve the health workforce, in many
instances, the success of these plans is dependent upon external donor assistance
(HRET, 2007; JLI, 2004; WHO, 2006, 2008). As much as 50 to 85 percent of the
recurrent healthcare budget of some countries in sub-Saharan Africa is consumed
by salaries for healthcare providers (Vujicic, 2005). Large increases in funding,
no matter what the source, are therefore necessary to scale up human resources
for health.
The current model of donor assistance does not support the long-term,
country-led investment that is required to help finance nationally owned strategies
for developing human resources for health. Development assistance and donor
grants tend to be unpredictable, volatile, and short term, making it difficult for
recipient governments to make long-term investments or to plan budgets using
external assistance (Lane and Glassman, 2007). Funds for hiring workers need to
be stable and long term in order to cover recurrent costs, such as salaries. Govern-
ments, therefore, may not wish to expand their health workforce any faster than is
sustainable in the long term with domestic resources (Vujicic, 2005).
In an interesting case in Malawi, a careful analysis of the health labor market
found a mismatch between the government’s great need for health workers and a
large available pool of skilled workers in the private sector who were unwilling
to work for public sector salaries. With assistance from the United Kingdom, the
Malawi government initiated a six-year plan to increase salaries in the health sec-
tor by 50 percent (Glassman et al., 2008). Preliminary assessment of the Malawi
program in its first three years of implementation shows an increase in practic -
ing health professionals in the public sector. In 2007, the physician and nurse
workforces increased 40 and 30 percent, respectively, compared to 2003. Medical
training infrastructure also improved—observable in the quadrupling of medical
training facilities between 2003 and 2006. To continue improvement in retention
and recruitment in the priority health fields, the Malawi plan aims to improve
incentives by offering a 52 percent salary increase (WHO and GHWA, 2008).
Recommendation 4-2. Federal executive branch agencies and departments,
nongovernmental organizations, universities, and other U.S.-based organiza-
tions that conduct health programs in low-income countries should align
assistance with the priorities of national health sector human resource plans
and should commit and sustain funding in support of these plans.
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THE U.S. COMMITMENT TO GLOBAL HEALTH
Consider Partial Solutions for Leveraging the U.S. Workforce
Given the overwhelming interest in global health, a relatively small number
of U.S. health professionals currently work in low- and middle-income countries.
Many health professionals volunteer with faith-based or secular nongovernmental
organizations, while several universities and corporations support health person -
nel in low-income countries through global health programs or research projects.
The U.S. government also sends small numbers of health professionals through
CDC and U.S. Agency for International Development projects (Mullan, 2007).
This relatively modest level of mobilization begs the question: If the resources
were made available, would a greater number of Americans in medicine, nursing,
public health, and the nontraditional health fields commit to service overseas? An
equally important question is whether or not an increase in U.S. expatriates and
volunteers would be a welcome resource in low-income countries. The level of
analysis necessary to answer both questions requires further investigation.
A 2005 study of nongovernmental organizations in sub-Saharan Africa found
a variety of volunteer opportunities ranging from two weeks to more than two
years at an estimated cost between US$36,000 and US$50,000 per expatriate
volunteer per year (Laleman et al., 2007). In general, the study found that most
country experts had experienced some interaction with hard-working, highly
motivated, and committed expatriate volunteers, who were willing to live and
work in remote areas. However, the study also found that volunteers tended to be
junior, inexperienced, and ill prepared to work in low-income countries for both
cultural and professional reasons. The use of volunteers in low-income countries
may require a more coordinated approach if this type of support is to provide a
partial solution to the human resource crisis in the global health sector.
The 2005 Institute of Medicine report Healers Abroad: Americans Responding
to the Human Resource Crisis in HIV/AIDS recommended that the federal govern-
ment create and fund an umbrella organization called the United States Global
Health Service (GHS) to mobilize the nation’s best healthcare professionals and
other experts to help combat HIV/AIDS in severely affected African, Caribbean,
and Southeast Asian countries. With a goal of building the capacity of targeted
countries to fight the pandemic over the long run (IOM, 2005), the GHS would
include, among several elements, a pivotal “service corps” made up of full-time,
salaried professionals. Other GHS staff would be stationed on the ground to provide
medical care and drug therapy to affected populations, while offering their local
counterparts training and assistance in clinical, technical, and managerial areas.
The committee finds that if a global health service model is deployed, the
mandate of the program should be broadened to include global health issues
beyond HIV/AIDS, emphasize training over service provision in the context of
providing patient care, and support bidirectional engagement (with U.S. profes -
sionals going abroad but also having professionals from low-income countries
come to the United States). Given that this type of program would require signifi-
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INVEST IN PEOPLE, INSTITUTIONS, AND CAPACITY BUILDING
cant resources, the committee considered whether or not scarce U.S. development
assistance dollars could be better spent supporting local country staff. While such
an investment would be an important opportunity for bidirectional knowledge
transfer, the committee recommends more detailed studies to determine the
demand for such a program (would mid- and advanced-career professionals be
willing to commit to a multiyear program?) and the degree of public health ben-
efit in recipient countries (would this type of support be well received by recipient
countries and would it be the most appropriate use of U.S. resources to address
the human resource crisis and improve global health outcomes?).
Another partial opportunity to address the global health resource crisis is by
considering the possibilities of “circular” migration as part of the solution. Many
migrants feel a strong sense of responsibility to their homelands and, having spent
some time abroad, would like to return home, perhaps temporarily, if conditions
for their return were right (International Organization for Migration, 2003). The
International Organization for Migration (2001) has implemented several volun-
tary return programs in Europe, Latin America, and Asia. In Africa, a program
called the Return and Reintegration of Qualified African Nationals successfully
stimulated the selective return of 2,565 urgently needed professionals in many
disciplines between 1983 and 1995. This still-fashionable paradigm continues
to tap into the skills and resources of the African diaspora by hiring emigrants
for short-term assignments and development activities in their home countries
(International Organization for Migration, 2001, 2002, 2003).
Policy barriers now limit the ability of health workers in the United States to
return to their country of origin to either train or practice their professions. These
barriers include the process of acquiring residency and naturalization and the lack
of portability of benefits, pensions, and insurance (Agunias, 2008). Yet there is a
desire on the part of migrants to see more temporary and circular migration. The
United States should consider more comprehensive policy options to encourage
circular migration to benefit both the countries that need labor and the countries
from which the workers come. A recent public opinion poll found that 81 percent
of Americans surveyed would support such a policy (WorldPublicOpinion.org,
2009).
Recommendation 4-3. Congress should work with federal executive branch
agencies and departments and U.S. universities to explore opportunities to
leverage the U.S. workforce to contribute to solutions that partially address
health workforce deficits in low- and middle-income countries. This explora-
tion should include an inquiry into the willingness of Americans to partici -
pate in a global health service corps; a determination of whether this kind of
assistance would be well received by recipient countries; and an examination
of whether specific opportunities exist to help migrants from low-income
countries return home to work temporarily or permanently.
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THE U.S. COMMITMENT TO GLOBAL HEALTH
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