You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Introduction {#S0001}
============

There were approximately 865 million people living in sub-Saharan Africa amidst multiple public health challenges and limited spending on public health in 2010 \[[@CIT0001]\]. Achieving public health goals in sub-Saharan Africa remains an elusive target despite major donor funded initiatives, some of which have been widely successful. For example, the United States (US) President\'s Malaria Initiative (PMI) led to a marked reduction in malaria transmission in a few short years \[[@CIT0002],[@CIT0003]\] and the US President\'s Emergency Plan for AIDS Relief (PEPFAR) markedly changed the fate of millions of HIV-infected people in the region and significantly reduced transmission of HIV from mothers to children \[[@CIT0004]\]. Sub-Saharan Africa also suffers considerable preventable mortality from maternal deaths, deaths due to motor vehicle crashes, cardiovascular diseases, and cancers \[[@CIT0005],[@CIT0006]\]. Effective public health surveillance and response systems allow countries to prioritize and address public health problems, but countries in the region have had challenges with developing robust systems and training the workforce to operate them \[[@CIT0007]\]. Africa is currently experiencing an economic resurgence; its overall economic growth in 2010 was 4.75% (similar to that of India) -- and several times that of developed countries and its projected growth in 2011 is 5.75%. Economists report that Africa appears to have escaped the worst of the global recession \[[@CIT0008],[@CIT0009]\]. With an improving economic outlook there is likely a growing demand for effective public health surveillance and response systems that can protect communities from communicable and non-communicable disease conditions.

In order to strengthen public health surveillance and response systems in sub-Saharan Africa, there is a need to develop a public health workforce capacity with competencies in field epidemiology. In 1993, the Rockefeller Foundation collaborated with the ministries of health (MOH) of Ghana, Uganda, Zimbabwe, and Vietnam to develop Public Health Schools Without Walls (PHSWOWs) as novel public health training programs that were tailored to improve public health surveillance and response and health services management needs at national and sub-national levels \[[@CIT0010],[@CIT0011]\]. Staff from the US Centers for Disease Control and Prevention (CDC) participated in the development of the Uganda and Zimbabwe PHSWOWs and both programs included a strong multi-disease surveillance and response training component which was based on CDC\'s Epidemic Intelligence Service (EIS) \[[@CIT0012]\]. Both the Uganda and Zimbabwe PHSWOWs recruited EIS graduates as expatriate resident advisors to develop 2-year Masters of Public Health (MPH) granting public health leadership programs with field work that enabled the trainees to develop competencies in field epidemiology comparable to those that EIS provides. These competencies were also similar to those provided by Field Epidemiology Training Programs (FETPs) which were developed as an adaptation of EIS to international settings beginning in the 1980s \[[@CIT0013]--[@CIT0015]\]. Ghana developed a 1-year MPH granting PHSWOW program focusing on district health management with a limited field epidemiology component without an expatriate resident advisor. All three African PHSWOWs had no specific training for public health laboratory workers.

In 2003, the Ellison Medical Foundation, the CDC Foundation, and CDC, collaborated with the Kenya MOH to start an innovative joint 2-year public health leadership training program for field epidemiologists and public health laboratory epidemiologists (public health laboratory scientists who are trained in field epidemiology and public health laboratory management) with a mission to create partnerships to operate disease surveillance and response systems, investigate suspected outbreaks, and manage public health laboratory networks. The Kenya Field Epidemiology and Laboratory Training Program (FELTP) was designed as a regional program with participants from Kenya, Southern Sudan, Tanzania, and Ghana. Uganda only participated in the laboratory epidemiology track (as they have their own PHSWOW). Soon after inception, with its added value of a laboratory epidemiology track, the Kenya FELTP became the model of the new generation of field epidemiology programs in sub-Saharan Africa which are now all FELTPs \[[@CIT0016]\].

In 2006, the public health threat posed by zoonoses particularly after human cases of avian influenza, and Severe Acute Respiratory Syndrome led to the recognition of the need to train veterinary epidemiologists in a specialty track in the FELTP. The intent was to create "one-health teams" who would be trained jointly to conduct surveillance and response to deal with the diseases occurring at the animal-human interface. To address this need, new and existing programs in sub-Saharan Africa started to train veterinarians along with physicians, other health scientists, and public health laboratory scientists to address zoonoses.

We describe the process that we used to develop 10 FELTPs covering 15 countries in sub-Saharan Africa over 6 years to develop a locally trained public health workforce that can operate multi-disease surveillance and response systems. By the end of 2010, these 10 FELTPs and the two PHSWOWs that were started in the 1990s covered an estimated 637 million of the 865 million people in sub-Saharan Africa and had enrolled 743 public health professionals.

Methods {#S0002}
=======

In 2003 we developed a standard process for implementing FELTPs as part of the creation of the first FELTP in Kenya. We have used this standard process for all the subsequent FELTPs in sub-Saharan Africa. Before starting the FELTP in each country, CDC received an invitation from the MOH which led to a cascade of activities, including: a) a pre-assessment visit, b) a formal assessment and program planning visit, c) identifying a funding source for the program plan, d) developing an MOH-led steering committee, e) developing and obtaining approval of the FELTP curriculum, f) recruiting key staff for the FELTP, g) implementing short courses in field epidemiology for key frontline staff and for screening of the initial cohort of FELTP participants, h) recruiting the first cohort of the FELTP, and i) implementing the 2-year FELTP. Each of these activities is described in detail below. For regional programs (FELTPs which involving more than one country) we adapted this process with more focus on the host country at startup of the regional FELTP.

The pre-assessment visits were conducted by a small team consisting of staff from CDC and existing FELTPs and PHSWOWs who visited the potential FELTP host country for about 1 week. The objectives of the visits were to gauge the interest of the MOH and its partners in starting an FELTP, to encourage the formation of an MOH-led Steering Committee, and to plan for the formal FELTP assessment and program planning visit. During the assessment and planning visits, conducted by a larger team usually 2-4 months after the pre-assessment, a representative sample of public health facilities at national and sub-national levels including public health laboratories were assessed using standard tools from the CDC FETP handbook to determine how they would participate in an FELTP \[[@CIT0017]\]. Local universities were also assessed to determine their interest in the FELTP training model (which has a limited didactic period). If they were interested we determined the process to obtain a university-endorsed and approved FELTP curriculum that would be adapted from the standard core FETP curriculum developed by CDC \[[@CIT0018]\]. Another team determined the cost of implementing an FELTP in the host country (and participating countries in a regional FELTP). At the end of each formal assessment we prepared an FELTP 5-year work plan including cost details and presented this to the first meeting of the FELTP Steering Committee. The Steering Committee, usually chaired by the highest ranking technical MOH official (e.g., the director of public health or chief medical officer), had representation from all the major stakeholders (e.g., CDC country office, World Health Organization representative, university senior leadership, public health laboratory service, veterinary service, and donors).

Implementation of the FELTP work plan began with the identification of resources for the program and selection of the university or universities to host the FELTP. In general most FELTPs began with a short course component to train frontline public health workers to address immediate field epidemiology, surveillance, outbreak investigation, and laboratory needs. The short courses were generally 2-weeks long and trained up to 30 participants per course. They were also used as screening courses for the first FELTP cohort, and were taught by a mix of international and regional FELTP and EIS graduates. Participants in the short courses had to develop and implement an applied learning project for 3 months at their worksites after the 2-week training as requirement for passing the course. These projects provided immediate benefit for the host country. Many countries conducted at least two short courses before starting the 2-year FELTP and these short courses continued along with the implementation of the FELTP.

The 2-year FELTP activities began with the recruitment of key staff, including at least one resident advisor who was usually a graduate of an FELTP or EIS or an experienced field epidemiologist, development of an FELTP office, finalization of the curriculum, and the advertisement and selection of the first cohort of the FELTP. The class size of the first cohort ranged from 10 to 15 with a mix of field epidemiology, public health laboratory, and veterinary candidates. The training strategy and competencies and expected outputs have been described elsewhere and are similar for all FELTPs in sub-Saharan Africa \[[@CIT0016]\].

In 2005 we collaborated with the US Agency for International Development (USAID), the three PHSWOWs (i.e., Ghana, Uganda, and Zimbabwe), and the Kenya FELTP to develop and then support the African Field Epidemiology Network (AFENET) which is a networking and service alliance of African FELTPs \[[@CIT0019]--[@CIT0021]\]. AFENET, which is headquartered in Uganda, has become CDC\'s principal implementing partner for developing, staffing, and operating FELTPs in sub-Saharan Africa. CDC has worked with AFENET to plan and develop FELTPs, to participate in organizing short courses, and to implement regional initiatives for FELTPs (e.g., regional biennial scientific meetings and regional training fellowships).

CDC provided technical assistance from Atlanta in the operation of the FELTPs through program specific teams that included field epidemiologists (generally graduates of the CDC EIS Program), instructional designers, public health advisors, and health education specialists. The Atlanta teams worked with the in-country resident advisors to provide assistance in program design, curriculum design, teaching, evaluation, quality assurance, direct funding, and fundraising. CDC staff worked collaboratively with FELTP program staff who were either host country MOH staff or host institution personnel and were led by a host country national that was the FELTP program director. In 2007, CDC began to maintain a tracking system for all field epidemiology training programs globally with information on participant numbers and outputs that was compiled annually into a report that is disseminated to key stakeholders \[[@CIT0022]\].

In 2008 we defined a series of critical outcome measures for FELTPs to better align them with their public health surveillance and response system strengthening mission \[[@CIT0015],[@CIT0023]\]. The following critical outcomes should be increasingly evident in the host country\'s MOH if the FELTP is successfully contributing to its mission: a) Functional and robust public health surveillance systems, often beginning with notifiable disease surveillance and then non-communicable disease surveillance systems; b) Prompt and effective response to public health emergencies including disease outbreaks and other public health threats; c) A culture of evidence-based decision making in public health whereby programmatic decisions are based on scientifically sound data; d) A strengthened and motivated public health workforce composed of FELTP graduates of the 2-year program and the short courses conducted for frontline (i.e., sub-national, regional, provincial) public health workers; e)Evidence that the FELTP is contributing to a reduction in morbidity and mortality from priority disease conditions.

Results {#S0003}
=======

In 2004, there were three 2-year field epidemiology training programs in sub-Saharan Africa: Kenya (which had a laboratory training component), Uganda, and Zimbabwe. By the end of 2010, there were 12 programs covering 17 countries, including Southern Sudan. The additional FELTPs include two regional programs in West Africa (with participants from Burkina Faso, Mali, Niger, and Togo, and headquartered in Ouagadougou) and Central Africa (with participants from Cameroon, Central African Republic, and Democratic Republic of the Congo, and headquartered in Yaoundé). Seven additional single-country FELTPs were created in Ethiopia, Ghana, Mozambique, Nigeria, Rwanda, South Africa, and Tanzania. The programs are in countries representing the three main official languages in the sub-Saharan region (English, French, and Portuguese). [Figure 1](#F0001){ref-type="fig"} shows all the field epidemiology training programs in the world as of 2010.

![Field Epidemiology Training and allied Programs, 2010](PAMJ-10-24-g001){#F0001}

Between 1993 and 2010 the 12 programs (10 FELTPs and two PHSWOWs) enrolled 743 public health professionals into the 2-year program, including graduates and current trainees in 2010. Of the 743, 624 (84%) were admitted into the field epidemiology training track, 95 (12.8%) were in the public health laboratory epidemiology track, 24 (3.2%) were in the veterinary epidemiology track ([Additional material 1](#T0001){ref-type="table"}). The countries covered by the programs accounted for approximately 637 million (73.6%) of the estimated 865 million inhabitants of the sub-Saharan region in 2010. By the end of 2010 at least 1000 frontline public health workers had been trained in several types of short courses in the countries with FELTPs.

###### 

Participants (Graduates and Current Trainees) of 2-year Public Health Schools Without Walls (PHSWOWs) and Field Epidemiology and Laboratory Training Programs (FELTPs) in Sub-Saharan Africa in 2010

  PHSWOW or FELTP             Country or Countries                                               Year PHSWOW or FELTP Began   Country or Region Population in 2010 (millions\]   Cumulative PHSWOW or FELTP Participants in 2010   Cumulative Participants per million 2010 population   Field Epidemiology Track (Degree offered)   Laboratory Epidemiology Track (Degree offered)                 Veterinary Epidemiology Track (Degree offered)   Source of Startup Funding
  --------------------------- ------------------------------------------------------------------ ---------------------------- -------------------------------------------------- ------------------------------------------------- ----------------------------------------------------- ------------------------------------------- -------------------------------------------------------------- ------------------------------------------------ ----------------------------
  1\. Zimbabwe PHSWOW         Zimbabwe                                                           1993                         12.6                                               166                                               13.2                                                  166(MPH)                                    n/a                                                            n/a                                              Rockefeller Foundation
  2\. Uganda NISWOW           Uganda                                                             1994                         33.8                                               284                                               8.4                                                   284 (MPH)                                   n/a                                                            n/a                                              Rockefeller Foundation
  3\. Kenya FELTP             Kenya, South Sudan                                                 2004                         48.3                                               74                                                1.5                                                   49 (MSc Applied Epidemiology)               25 (MSc Applied Epidemiology and Laboratory Management         n/a                                              Ellison Medical Foundation
  4\. South Africa FELTP      South Africa                                                       2006                         49.9                                               41                                                0.8                                                   24 (MPH Field Epidemiology)                 17 (MPH Field Epidemiology and Laboratory Management)          n/a                                              PEPFAR
  S. Ghana FELTP              Ghana                                                              2007                         24.0                                               28                                                1.2                                                   10 (MPhil Applied Epidemiology)             9 (MPhil Applied Epidemiology and Laboratory Management        9 {MPhil Applied Epidemiology)                   USA ID
  6\. Tanzania FELTP          Tanzania                                                           2008                         45.0                                               33                                                0.7                                                   20 (MSc Applied Epidemiology)               13 (MSc Applied Epidemiology and Laboratory Management         n/a                                              PEPFAR, USA ID, PMI
  7\. Nigeria FELTP           Nigeria                                                            2008                         158.3                                              26                                                0.2                                                   12 (MSc Field Epidemiology)                 6 (MSc Field Epidemiology and Laboratory                       8 (MSc Veterinary Field Epidemiology)            PEPFAR, USA ID
                                                                                                                                                                                                                                                                                                                                     Management)                                                                                                     
  8\. Ethiopia FELTP          Eihiopia                                                           2009                         85.0                                               35                                                0.4                                                   29 (MPH)                                    6 (MPH)                                                        n/a                                              PLPhAR
  9\. Rwanda FELTP            Rwanda                                                             2010                         10.4                                               15                                                1.4                                                   (MSc Applied Epidemiology)                  3 (MSc Applied Epidemiology and Laboratory Management          3 (MSc Applied Epidemiology)                     PLPhAR
  10\. West Africa FELTP      Burkina Fa so, Mali, Togo, Niger                                   2010                         54.1                                               12                                                0.2                                                   4 (MPH)                                     4 (MPH)                                                        4 (MPH)                                          USAID
  11\. Mozambique FELTP       Mozambique                                                         2010                         23.4                                               11                                                0.5                                                   5 (MSc Applied Epidemiology)                6 (MSc Applied Epidemiology and Laboratory Management          n/a                                              PEPFAR
  12\. Central Africa FELTP   Democratic Republic of Congo, Cameroon, Central African Republic   2010                         92.6                                               18                                                0.2                                                   12 (Master\'s in Field Epidemiology)        6 (Master\'s in Field Epidemiology and Laboratory Management   n/a                                              BMGF USAID
                                                                                                 TOTAL                        637.4                                              743                                               1.2                                                   624                                         95                                                             24                                               

FELTP = Field Epidemiology and Laboratory Training Program, FETP= Field Epidemiology Training Program

PEPFAR = US President\'s Plan for Emergency AIDS Relief; PMI= US President\'s Malaria Initiative; USAID = US Agency for International Development; BGMF= Bill and Melinda Gates Foundation

MPH = Masters of Public Health; MSc = Masters of Science; MPhil = Masters of Philosophy

There were approximately 0.86 public health professionals who had participated in a 2-year FELTP or PHSWOW per million inhabitants in sub-Saharan Africa. In the 17 countries with programs there were approximately 1.2 FELTP or PHSWOW participants per million inhabitants, which is less than the estimated minimum coverage of 3-5 field epidemiologists per million inhabitants of a country \[[@CIT0023]\]. All the sub-Saharan programs award a master\'s degree to participants upon completion of university requirements, some programs provide the same type of degree to field epidemiologists, public health laboratory epidemiologists, and veterinarians whereas other programs have different track-specific degrees (Table 1).

Of the 12 programs started between 1993 and 2010, six (50%) received startup funding from PEPFAR, and five (42%) received funding from USAID. Other funders included the Bill and Melinda Gates Foundation, and PMI. Host country MOHs (and ministries of agriculture for programs with veterinarians) also contributed significant resources, usually in kind (e.g., space for the program, ancillary facilities, and field sites). CDC provided supplementary funding through various initiatives for example the Global Disease Detection program in Kenya from 2006 and PEPFAR provided some support to the Zimbabwe PHSWOW \[[@CIT0016],[@CIT0024]\]. The donor cost of implementing an FELTP ranges between US \$ 1-2 million per year at inception. These costs reduced with time as expatriate staff left and the program transitioned to local staff (usually graduates of the initial cohorts) and host government funding began to replace donor funding. The costs associated with implementation include: a) resident costs which include university tuition, stipends, books, computers, and research costs; b) program costs which include emergency response, local and international travel, program office operations, field supervision visits, field site maintenance; and c) technical assistance (from Atlanta, which supports the country team); and d) resident advisor salary and support.

Discussion {#S0004}
==========

In 2004 there were three 2-year field epidemiology training programs in sub-Saharan Africa, two PHSWOWs and one FELTP. By the end of 2010 there were 12 programs, two PHSWOWs and 10 FELTPs, representing a fourfold increase in 6 years. This increase coincided with PEPFAR and USAID support of health systems strengthening and efforts to roll out WHO-AFRO\'s Integrated Disease Surveillance and Response strategy \[[@CIT0004],[@CIT0025]\]. Development of a standardized process guided by FELTP host countries' MOHs and involving all key stakeholders was critical for program implementation. Linking field epidemiology training first with the development of public health laboratory epidemiology as a new competency, and then training veterinarians to specifically address the diseases at the human-animal interface broadened the public health workforce available to operate multi-disease surveillance and response systems. Including a strategy to train frontline public health workforce through short courses also strengthened basic multi-disease surveillance and response systems with 2-year FELTP graduates often leading other trained public health professionals in joint field investigations. The 10 FELTPs and two PHWOWs had enrolled a total of 743 public health professionals in their 2-year programs by the end of 2010.

Field epidemiology training programs have been the basis on which public health surveillance and response systems have been developed around the world. CDC\'s EIS program, now in its 60th year has been the backbone of CDC and US State health departments' surveillance and response systems. Similarly FELTPs are proven strategies for developing public health surveillance and response systems and can be adapted to address various public health issues. The link between 2-year training and short courses allows for flexibility to develop different but complementary skill sets within a country. Some countries, particularly those emerging from conflict situations may not be able to develop 2-year degree granting FELTPs but may be able to conduct FELTP short courses while sending a few public health professionals to a nearby FELTP to gain the competencies to start their own program. This strategy is currently underway between Southern Sudan and the Kenya FELTP, and Sierra Leone and the Ghana FELTP.

The long-term success of FELTPs depends on their sustainability. The Uganda and Zimbabwe programs have sustained since the 1990s but the path to sustainability is not pre-determined and requires several issues to be in sync. The PHSWOWs in Uganda and Zimbabwe were the first programs of their nature and were designed to develop a specific cadre of public health professionals who were virtually guaranteed of jobs utilizing their new competencies upon graduation. Both programs also included substantial training in health services management, and many graduates ended up heading district, provincial and national public health programs. FELTPs, which are developed with a closer link than PHSWOWs to development of national multi-disease surveillance and response systems and institutionalization of rapid response to public health emergencies, may require a redesign of existing public health systems to develop career paths for field epidemiologists and public health laboratory epidemiologists. Whereas the initial graduates from FELTPs can be absorbed into existing positions at national and sub-national level, the long-term sustainability of these programs requires the development of specific positions that can utilize their training appropriately. Increasingly countries are being encouraged to develop national public health institutes which can be a natural location of an FELTP at the central level \[[@CIT0026]\].

Continued funding for FELTPs, which have substantial field work as part of their training strategy is an ongoing challenge. PEPFAR and USAID have provided significant support for FELTP development and starting planned programs (in Angola, Zambia, Namibia, and Botswana) is currently contingent on obtaining PEPFAR funding. Partnerships with private sector organizations and other potential funders for FELTPs will have to be developed to sustain existing programs beyond their initial funding and to start new programs where none exist. Africa in general has an improving economic climate as its natural wealth increases in value and as an African middle class develops there will likely be a need and possibly a demand for improvements in public health surveillance and response systems which can be developed and operated by locally trained FELTP graduates with funding from national governments or domestic non-governmental organizations.

Traditionally FETPs around the world typically had limited interaction with universities. However all FELTPs and PHSWOWs in sub-Saharan Africa have links with a local university and all grant master\'s degrees when participants complete the university requirements, which usually includes successfully defending a master\'s dissertation. This is a common key requirement by all the FELTP steering committees, mainly to enhance the career prospects of the FELTP graduates. Universities also provide an academic anchor for the FELTP which leverages the credibility of the universities as the program starts up. The university faculty assists in teaching the didactic components of the course and the FELTP staff strengthens the university faculty by showing them how the field-based training model works, creating shared value between the FELTP and the university. Each FELTP student has an academic supervisor or mentor from the university in addition to the program and field site supervisors. Involvement with the universities ensures that the courses are offered on time every year through a competitive selective process which helps in ensuring sustainability.

There is an ongoing discussion on how many FELTP and similarly trained public health workers are required to implement robust multi-disease surveillance and response systems in developing countries. Some authors have suggested that 3 to 5 FELTP graduates per million inhabitants in a country are needed, with a mix of field epidemiology, public health laboratory epidemiology, and veterinary epidemiology \[[@CIT0023]\]. Based on this estimate sub-Saharan Africa would need between 2,600 and 4,500 FELTP graduates or similarly trained public health personnel for its population figures in 2010. Uganda with a population of 34 million in 2010 would require between 100 and 170 graduates and Zimbabwe would require a maximum of 65 graduates for a 13 million population. Both Uganda and Zimbabwe have exceeded these targets, and have a high retention of their graduates but still have challenges in their public health surveillance and response systems and continue to conduct training in their programs to strengthen public health systems \[[@CIT0027]\]. We believe that beyond the number of FELTP and PHSWOW graduates there is a complementary need to develop functional and networked multi-disease surveillance and response units at national, provincial, and district levels. These units would need to be operated by a mix of FELTP and PHSWOW graduates and short course participants. It has been suggested that with functional networked multi-disease surveillance and response units, fewer graduates may be needed to operate a basic but robust public health surveillance and response system \[[@CIT0023]\]. We suggest that a goal of having at least one functional multi-disease surveillance and response unit per million inhabitants in a country is worthwhile and feasible in sub-Saharan Africa. These units which would be operated by FELTP graduates and short course participants would be networked to form a multi-disease surveillance and response system for the country.

We have described how a standardized process led to the development of 10 FELTPs in sub-Saharan Africa from 2004 to 2010 but at least four challenges need to be noted. First, while we believe that all these FELTPs will be sustainable like the Uganda and Zimbabwe programs, we cannot be absolutely certain. Nevertheless, the environment that led to the creation of these programs in response to a need for a locally trained public health workforce that can operate disease surveillance and response systems for multiple conditions is likely to persist. We also believe that involvement of a high level MOH-led Steering Committee to oversee FELTP activities is likely to maintain these programs. Second, the FELTP model is still a relatively new endeavor that attempts to link public health laboratory epidemiology and field epidemiology workforce development which will need to be adapted to suit particular country environments, especially given the different career paths of the graduates of these programs. Third, the FELTPs being field-based programs require competent, committed field supervisors and field sites that are suitably equipped to host trainees with substantial funding for field operations. This can be a challenge when the program is starting as very few people in the country are familiar with this training model. If funding for field sites diminishes there may be a reduction in their quality and the overall quality of the FELTP, which depends on maintenance of appropriate field-based training. Finally, the link between FELTPs and the development and funding of the appropriate structures at national and sub-national level to absorb FELTP graduates requires ongoing work with non-health stakeholders (e.g., the legislature, the ministries of finance and public service, and the private sector).

Conclusion {#S0005}
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The FELTP model is one proven strategy for developing a locally trained multi-disciplinary and cohesive public health workforce that can operate several public health surveillance and response systems. We have shown this strategy can be implemented in sub-Saharan Africa, an area of the world that has numerous public health challenges--but is also experiencing an economic renaissance which will likely lead to a greater demand for strong public health surveillance and response systems to protect communities. We believe that now is the time for all sub-Saharan countries to invest in public health workforce development by implementing FELTPs or by sending public health professionals to a nearby FELTP, and to use the graduates to develop the systems and the structures that will enable a public health renaissance to accompany the economic renaissance.

Additional material {#S0006}
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Participants (Graduates and Current Trainees) of 2-year Public Health Schools Without Walls (PHSWOWs) and Field Epidemiology and Laboratory Training Programs (FELTPs) in Sub-Saharan Africa in 2010

Competing interests {#S0007}
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The authors declare no competing interests

Authors contributions {#S0008}
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All the authors were involved in designing and implementing the programs that are described in this manuscript. All the authors participated in the drafting of this manuscript and reviewed the final draft. Peter Nsubuga is the corresponding author.

Acknowledgements {#S0009}
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Juliette Mannie and Chandra Smith who provided very valuable help in implementing this work; the program directors and staff of all the FELTPs in sub-Saharan Africa; David Mukanga and the staff of the African Field Epidemiology Network.