The last several years have seen a remarkable increase in funding for global health [1
]. Most of these new resources for global health come tightly linked to addressing specific disease problems, e.g. immunizable diseases or HIV/AIDS. Despite the important accomplishments of this approach, it has been increasingly recognized that this vertical funding and its accompanying structure does not automatically address and may worsen the underlying issues that severely reduce the capacity to respond to each disease [4
]. The most critical constraint to effective response is weakened infrastructure and systems of public health. The rapid expansion of programmes in such contexts can easily lead to only short-term impacts and further weakening of public health infrastructure [6
Many of these new resources may be wasted if human resource constraints are not addressed [7
]. The clear challenges facing the public health workforce, particularly in developing countries, have been well documented [9
]. This is a critical component of the global human resource crisis that is limiting the ability of the world to respond effectively to health crises [2
]. The HIV/AIDS crisis in sub-Saharan Africa has exacerbated the problem, both by increasing the magnitude of the health crises and diminishing the number of available health workers [2
]. Countries applying to the Global Fund to Fight AIDS, Tuberculosis and Malaria have consistently identified human resources as a top priority for health system strengthening [6
In difficult environments, where few trained persons might be available, it has been very tempting for international organizations to hire away well-trained persons from national institutions for specific small projects, typically funded by nongovernmental organizations (NGOs) [7
]. Because of the great resources for HIV/AIDS, AIDS programmes are perhaps at particular risk for this unintended consequence. This may lead to a successful small project but can inadvertently undermine the long-term goals of capacity strengthening and institution building. This has been especially true in the context of the HIV/AIDS epidemic in developing countries [2
]. This problem has now been recognized and acknowledged by the donor community and the countries, which increasingly plan to better coordinate aid to support national health systems rather than focusing exclusively on disease-specific priorities[15
Zimbabwe is one of the countries most severely affected by HIV/AIDS. The estimated HIV prevalence in 2003 was reported at 24.6% [17
]. In 2000, increased funds for responding to the epidemic in Zimbabwe became available through the United States Centers for Disease Control and Prevention's (CDC) Global AIDS Program (GAP). Like many countries, Zimbabwe faced the problem of absorption capacity: limited capacity to translate new financial resources into effective programmes.
In particular, the number of persons trained for leadership and management of new HIV intervention programmes was insufficient. Inadequate remuneration for public health officials and faculty was leading to loss of staff, or to staff working extra jobs to compensate for poor public sector salaries, thus limiting time available both to perform public health tasks and train public health staff. A related problem, as alluded to above, was "internal brain drain" reflected by hiring of national public sector staff to work on internationally funded HIV projects, further draining the necessary coordinating capacity and infrastructure [7
Zimbabwe had long recognized the need for locally trained public health professionals. A Masters in Public Health (MPH) programme using the applied epidemiology training programme model had been started in 1994 through support of the Public Health Schools without Walls (PHSWOW) Programme of the Rockefeller Foundation and has continued with support from CDC's Division of Global Public Health Capacity Development (DGPHCD) (formerly Division of International Health (DIH) [10
]. PHSWOWs were developed as partnerships between ministries of health and universities. Applied epidemiology training programmes, also known as field epidemiology training programs (FETP) are designed to build human capacity in health service agencies by providing training in field epidemiology and other public health competences in the context of health service delivery systems [18
The Zimbabwe MPH programme began in 1993 as a joint effort of the Ministry of Health and Child Welfare (MOH) and the Department of Community Medicine at the University of Zimbabwe (UZ). A CDC advisor was resident in Zimbabwe during 1994–1996. During 1994–2000, a total of 41 trainees graduated. Most trainees were physicians and nurses, but pharmacists, veterinarians, nutritionists, laboratorians and other health staff were trained.
The programme was well respected and well integrated into the public health system and the MOH, as indicated by the fact that the majority of graduates were employed within the national public health system at either national-level positions in MOH, as Provincial Medical Directors or as City Health Directors. However, with only four to eight graduates per year, the number of public health professionals still did not meet the country's needs. In addition, the MPH curriculum in Zimbabwe had not been updated in response to the emergence of the HIV/AIDS crisis. Despite the >50% national burden of disease attributable to HIV in Zimbabwe [23
], the focus on HIV was limited, with only three of 41 MPH dissertation topics during 1994–2000 being HIV/AIDS-related.
When CDC GAP began to work in Zimbabwe in 2000, despite 10 years of Zimbabwean research and reports on HIV/AIDS, there was limited implementation of truly nationwide HIV prevention and treatment programmes to slow the epidemic and attenuate its impact. CDC GAP, together with the MOH, jointly developed specific goals related to HIV prevention and control for Zimbabwe. These included expansion of Prevention of Mother to Child Transmission of HIV (PMTCT), expansion of HIV testing capacity, improved understanding of the epidemic through better surveillance methods, behavioural interventions, improvement of care for opportunistic infections and introduction of antiretrovirals (ARV) throughout the country.
A key supporting strategy of CDC GAP was to build human capacity and strengthen the existing health institutions to provide the needed leadership in a sustainable way. This paper describes one specific collaborative effort, begun in 2001, that built on the strength and resources of many partners to respond more effectively to the HIV/AIDS epidemic by reinforcing a crucial training institution and thereby expanding production of epidemiologists and public health leaders.