GHI will provide an opportunity for major investments in sustainable health systems strengthening and public health systems strengthening in developing countries. With an estimated USD 63 billion investment in global health, GHI will be the principal engine for global health development for the foreseeable future. The President’s Emergency Plan for AIDS Relief (PEPFAR) reauthorization, which is part of GHI, includes the goal of pre-service training for 140,000 new health care workers within five years in the recipient countries . We believe that these new health workers will need to respond by providing both treatment and preventive service, and that the number of public health workers needed to make a significant change in the operation of public health systems is substantially less than number of health care workers needed for curative health care services. While the focus of public health system strengthening has previously been aimed at treatment of disease, the advent of emerging pandemics necessitates incorporation of other specialties including epidemio-logic, laboratory and management expertise. In our experience, a successful way to strengthen public health surveillance and response systems is through Field Epidemiology and Laboratory Training Programs (FETPs and FELTPs) or allied programs (e.g., Public Health Schools Without Walls)  and through competency-based short courses, mainly those in basic field epidemiology for frontline surveillance and response staff .
FETPs /FELTPs provide a critical component of the public health workforce that is needed to operate public health surveillance and response systems to implement the IHR(2005) . FETPs/FELTPs are modeled on the successful Epidemic Intelligence Service (EIS) training that has been offered by the U.S. Centers for Disease Control and Prevention (CDC) since the 1950s. EIS has been responsible for developing U.S. public health surveillance and response systems at the federal and state level. FETPs/FELTPs are often started with donor funding (e.g., the U.S. Agency for International Development [USAID], the World Bank, and lately PEPFAR) and CDC technical assistance, and are designed to transition to host government funding. FETPs/FELTPs train public health personnel using a two-year long competency-based residency approach where trainees provide public health service to the ministry of health during their training. Many FETP/FELTP programs offer a masters degree or the equivalent at the end of the two-year postgraduate training. Graduates of the programs are able to operate national and sub-national public health surveillance and response systems, with growing responsibility as they gain experience. Increasingly FETPs/FELTPs are designed with a goal of contributing to the following critical outcomes within five to ten years after startup in the host country:
functional and robust public health surveillance systems, often beginning with notifiable disease surveillance systems and moving on to add non-communicable disease surveillance systems;
prompt and effective response to public health emergencies, including disease outbreaks and other acute public health events;
a culture of evidence-based decision making in public health whereby programmatic decisions are made on scientifically sound data;
a strengthened, motivated public health workforce comprising public health leaders (i.e., graduates of the two-year FETP/FELTP course) and frontline public health implementers (i.e., graduates of the in the short courses that are associated with the program); and
reduction in morbidity and mortality from priority diseases in the host country.
Although no precise studies have been done to establish a target for the public health workforce, for a basic multi-disease public health surveillance and response system to be operational in a developing country, certain core public health positions and structures are critically needed at the national and sub-national level. At the sub-national level, a province, or region, comprised of several districts is commonly the point of primary public health program implementation. We believe that a province or region should have at least three FETP/FELTP graduates to operate basic multi-disease public health surveillance and response systems: one to lead communicable and non-communicable disease surveillance; one to lead communicable and non-communicable disease control; and one to lead the public health laboratory network for the province. These graduates should be working together within a provincial disease surveillance and disease control unit reporting to the provincial medical director and with a complement of district-based frontline staff that are trained in basic field epidemiology and public health laboratory practice as they jointly operate public health systems within the province. Larger provinces may need to have more graduates to address specific diseases and graduates may even be deployed at the district level in smaller countries.
At the national level, a team of FETP/FELTP graduates working in a national multi-disease surveillance, disease control, and public health laboratory unit or department should be linked to the provincial disease surveillance, disease control, and public health laboratory units to form a robust national multi-disease surveillance and response network. More FETP/FELTP graduates may be needed for specific programmatic needs at the national level (e.g., to operate the HIV, TB or malaria programs). Some health ministries may need to train a cadre of public health managers and logisticians for the public health systems to operate efficiently. The multi-disease surveillance, disease control, and laboratory network positions at national and sub-national level would then form the core public health positions that are necessary for essential public health actions to occur within the country. The national and provincial multi-disease surveillance and disease control departments and units would form the network through which these essential public health functions would be conducted.
We believe that a country would have an adequate coverage of public health workers trained in the FETP or FELTP if there are three to five graduates per million inhabitants in the country, to reach adequate coverage an FETP or FELTP would need to be operating for more than 5-10 years.
FETPs/FELTPs have developed international and regional networks (e.g., Training in Public Health Interventions Network (TEPHINET, http://www.tephinet.org) , and the African Field Epidemiology Network (AFENET, http://www.afenet.net) ), that are playing a major role in networking trainees and graduates for effective public health surveillance and response systems. AFENET, for example, is supporting graduates to implement various public health surveillance and response activities in the health ministries of member countries, and TEPHINET and AFENET trainees and graduates have participated in international outbreak investigation and management teams under the auspices of the WHO.
Many FETPs/FELTPs are currently operated by their host country nationals and have transitioned from direct donor funding. Examples of programs that have transitioned from donor funding in Africa include those in Zimbabwe and Uganda. Most programs have a steering committee that is led by the ministry of health and includes all important stakeholders (e.g., the host country university, donors, the WHO, etc.) The steering committee shepherds that vision of the program which includes career paths for the graduates, a plan for sustainability, and a plan for transitioning from donor funding. Many programs are led by graduates of the initial cohorts of trainees, including those in Brazil, Thailand, and Kenya.