Sallie Thieme Sanford Sallie Thieme Sanford is an Assistant Professor at the University of Wash­ ington School of Law, with an adjunct appointment in the University of Washington School of Public Health. She received her B.A. with honors from Brown University and her J.D., Order of the Coif, from the University of California at Los Angeles. She began her legal career as a law clerk for The Honorable Robert R Bee­ zer of the United States Court of Appeals for the Ninth Circuit. She then served as an Assistant Attorney General representing the University of Washington Medical Center, Harborview Medical Center and the UW's health sciences schools and research centers. Professor Sanford has been active on the board of the Washington State Society of Healthcare Attor­ neys and recently served as its president. Professor Sanford's research in­ terests focus on health care delivery systems, health administration law, Medicare and Medicaid, comparative health law, and medical and adminis­ trative ethics. I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I TEACHING HEALTH LAW IN RURAL ETHIOPIA: USING A PEPF AR PARTNERSHIP FRAMEWORK AND INDIA'S SHANBAUG DECISION TO SHAPE A COURSE Sallie Thieme Sanford• I. INTRODUCTION ............................................................................... 487 n. HARAMAvA UNIVERSITY ............................................................... 488 lll. OVERVIEW OF THE COURSES .......................................................... 490 N. SHANBAUG AND MEDICAL DECISION-MAKING ............................... 492 V. PEPF AR PAR1NERSHIP FRAMEWORKS AND POPULATION HEALTH .......................................................................................... 495 VI. SOME PRACTICAL OBSERVATIONS ................................................. 499 Vll. CONCLUSION .................................................................................. 501 I. INTRODUCTION In April 2011, I taught a month-long intensive health law course at Haramaya University College of Law in rural eastern Ethiopia. Given the burgeoning interest in global health law, I suspect, and hope, that others are considering teaching similar courses, whether as visiting or resident faculty. This essay attempts to ease their course preparation workload. I will de­ scribe how I used two recent documents-India's 2011 Shanbaug decision1 and Ethiopia's 2010 PEPFAR Partnership Framewor~-to shape the course. Both of these are worth consideration for use in a variety of health law and policy courses based in low-income countries with rapidly expand­ ing health systems. Some aspects of my experience might also be helpful for other foreign teachers. The Shanbaug case offers a useful introduction to various issues of law and ethics in individualized medical decision-making. It involves the publicly prominent case of an Indian woman who has for nearly four dec­ ades met "most of the criteria for being in a permanent vegetative state.'.l • Assistant Professor of Law, Adjunct Assistant Professor of Health Services, University of Washington. I am grateful to Joan Altman, JD, MPH, for her fine research assistance, to Christopher Sanford, MD, MPH, for his invaluable insights, and to my colleagues at Ha­ ramaya University and the University of Washington for their helpful comments. And, of course, to Richard Wentzell, JD, Ph.D., for facilitating this great teaching and learning expe­ rience. 1. Shanbaug v. Union of India, Writ Petition (Criminal) 115 (2009) (India Mar. 7, 2011 ), available at http://judis.nic.inlsupremecourtlchejudis.asp. 2. Five-Year Partnership Framework in Support of the Ethiopian National Response to HIV/AIDS 2010-2014, U.S.-Eth., Oct. 27, 2010, available at http://www.pepfar.gov /documents/organization/154198.pd([hereinafter "Ethiopia PF'1· 3. Shanbaug, slip op. at 14. 488 INDIANA HEALTH LAW REVIEW [Vol. 9:2 In legalizing and setting forth procedural guidelines for what it termed "passive euthanasia," 4 the Supreme Court of India surveys medical deci­ sion-making law from a number of jurisdictions and explicitly considers its applicability to India's legal and cultural contexts. As of January 2012, nineteen countries and two regions have entered into PEPF AR Partnership Frameworks. 5 These documents propose a varie­ ty of country - or region-specific health policy reforms. Studying these proposals could focus discussion on the law's potential role in promoting population health in a given country. In addition, depending on the school's location and the issues of academic interest, a Partnership Frame­ work could provide an opportunity for timely problem-based learning in conjunction with affiliated health sciences faculty, policymakers, or local advocacy groups. I found that these documents helped shape an engaged class, and hope that others might take them far beyond what I did. My use of them in a short seminar at Haramaya University can be considered a beta test. I also mention here some other resources that helped me prepare for this law class and also for School ofNursing classes I taught during the same visit. Final­ ly, I offer some of the lessons I learned as a first-time foreign teacher not accustomed to a campus with hyenas. 11: HARAMAYA UNIVERSITY With a population of more than 80 million, Ethiopia is the second most populous country in Sub-Saharan Africa. It is a low-income country with a real per capita income of $232 United States dollars a year and near­ ly 40% of the population living below the international poverty line of $1.25 a day. It is also one of the least urbanized countries, with more than 80% of the population living in rural areas.6 Although Ethiopia has made gains in a number of health-related indicators in recent years, its health sta­ tus and system indicators remain low. Life exrectancy is 53 years, and the infant mortality rate is 77 per 1,000 live births. Haramaya University, formerly known as Alemaya University, is one 4. Id at41-45. 5. For a current list and links, see Partnership Frameworks, U.S. PRESIDENT's EMERGENCY PLAN FOR AIDS RELIEF, http://www.pepfar.gov/frarneworks/index.htm (last visited June 4, 2012). 6. Ethiopia PF, supra note 2, at 6. 7. !d. at 6-8. By comparison, in 2010 the United States life expectancy was 78.7 years of age and the infant mortality was 6.14 per 1,000 live births. See Sherry L. Murphy et al., Deaths: Preliminary Data for 2010, 60 NAT'L VITAL STATS. REPS., Jan. 2012, at 6, 9, available at http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf. A nice interactive website for comparative health status and systems comparisons is available at Which coun­ tries are faced with a 'critical' health worker shortage?, GUARDIAN, Jan. 17, 2011, http:l/www.guardian.eo.uk/global-health-workers!interactive/infographic-mortatlity-rates­ health-workers-uk-us-worlld. 2012] TEACHING HEALTH LAW IN RURAL ETHIOPIA 489 of Ethiopia's oldest, having been founded in 1954 as an agricultural college on the shores of the now extinct Lake Haramaya. 8 The 1 ,500-acre main campus is located in Ethiopia's Oromia region, the least populated area of the country. In addition to the academic buildings, sports facilities, housing and cafes for the approximately 17,000 resident students, faculty, and staff, the spacious campus features crop fields, greenhouses, poultry barns, and livestock, ·including camels.9 The university has expanded significantly over the years to include, among its many programs, colleges of law, nurs­ ing, medicine, and public health. The College of Law ("HU Law"), founded in 2002, offers a five-year LLB program and will graduate approximately 140 students in 2012. Ethio­ pia is a civil law country, with some elements of common law based on precedent, as well as interaction with customary and Shaiia law.10 In 2012 the law school plans to publish its first law review and begin an LLM pro­ gram. Its current dean is University of Washington Law School ("UW Law") graduate Richard Wentzell, JD, Ph.D. HU Law and UW Law now have a number of other academic alliances, furthered by a memorandum of understanding signed in 2011.11 For example, the two schools are collabo­ rating on a Land Tenure Institute to help develop and improve rural land law and policy, and have exchanged students and faculty. 12 Haramaya University's rapidly expanding colleges of medical and health sciences are located 15 kilometers away in Harar, just outside the walls of this ancient Islamic city. The Health Sciences College was found­ ed in 1996, and now includes schools of nursing and midwifery, public health, environmental health and laboratory technology.13 The Medical Sciences College, which will graduate its first class in 2013, recently as­ sumed management of the nearby 200-bed Hiwot Fana Hospital and its as­ sociated clinics.14 The medical school class to graduate in 2013 includes 60 8. See Welcome to Haramaya University, liARAMAYA UNIV., http://www.haramaya. edu.et/ (last visited Jan. 12, 2012). For a fuller Wlderstanding of the University's history and roles, I am grateful to President Belay Kassa, Ph.D., and to the recently opened on-campus museum devoted to Haramaya's history. 9. In all of is programs, including distance and summer learning, approximately 31,000 students were enrolled in 2011. Id 10. The GlobaLex website is one helpful resource for summary information on the legal systems of a number of colDltries. Tools for Building Foreign, Comparative and Inter­ national Law Collections, GLOBALEX, http://www.nyulawglobal.org/Giobalexl (last visited May 18, 2012). 11. See 64 UW L. ALuMNI MAG. 37-40 (Fall 2011), available at http://issuu.com/ uwschoolotlaw/docs/uwlaw _magazine_fall2011 ?mode=window&pageNumber=38. 12. Id See also Catherine O'Donnell, Law Students from Ethiopia Learn as Part of Nation Building, UW TODAY (Dec. 2, 2011 ), http://www. washington.edu/news/articles/law­ students-ftom-ethiopia-learn-as-part-of-nation-building. 13. Thanks to Health Sciences College Dean Biftu Geda and Nursing and Midwifery School Head Dereje Meaza for their helpful introduction to these programs. and gracious assistance throughout the visit 14. College of Medical Sciences Dean Takaba Abdosh, MD, provided a personal tour 490 INDIANA HEALTH LAW REVIEW [Vol. 9:2 students; the class of2017 has 220. 15 The nursing school has seen a similar rapid expansion across its programs.16 HU's Harar Bulletin of Health Sci­ ences published its inaugural issue in 2011, with an edition focusing on HIV I AIDS research.17 After participating in a HU Law conference in 2010, I was invited to return and teach a course or courses for law and health sciences students. My husband, Christopher Sanford, MD, MPH, was also invited to interact with the medical school and hospita1.18 Our sons Nate and Henry, then twelve and ten, came as well, and attended the l~al public school.19 lll. OVERVIEW OF THE COURSES Ultimately, I ended up teaching separate courses on the two Haramaya campuses in April 2011.20 The ''Seminar in Current Health Law Issues" included eighty-three upper-level law students, met twice a week, and re­ quired two papers and two quizzes. It was intended to provide an overview of current legal issues involving individual medical decision-making and also of the role of the law in promoting population health. I shaped this course around Ethiopia's Partnership Framework and India's Shanbaug de­ cision, both ofwhich are discussed below. In the nursing school, I taught an "Ethical Issues in Health Care'' module to eighty first-year nursing stu­ dents and facilitated classes with upper-level nursing students. These ses­ sions coalesced around small group discussions of hypotheticals I drafted based on ·medical literature,21 a nursing textbook, 22 and discussions with of the hospital and research offices, as weU as useful information about the program. 15. Email from Health Sciences College Dean Biftu Geda, Jan. 15, 2012, on file with author. 16. /d. 17. liARAR BULL. HEALTH SCI., http://www.haramaya.edu.et/index.php?option=com_ conten~view=article&id=427&1temid=211 (last visited June 10, 2012). 18. Chris has a relevant background, being a family practice doctor with a specialty in travel and tropical medicine as weU as appointments at the University of Washington School of Medicine and Department of Global Health. He also is one of the founders of the East Africa Diploma Course in Tropical Medicine. This 12-week program. which had its first full session in 2011, is based in Tanzania and Uganda. A number of the student slots are re­ served for African physicians, who pay a lower tuition than the other students. See About, E. AFR. DIPLOMA CoURSE IN TROPICAL MED., http://www.tropmedafrica.org/ (last visited June 2, 2012). 19. The Model School is located on campus and encompasses grades kindergarten through twelfth grade. The principal, Basha Haile, teachers, and students were very accom­ modating and helpful, with English teacher Solomon BeShahwred facilitating arrangements. Our boys joined the seventh grade, the year in which most instruction begins to be in English rather than in Ambaraic or Oromo. 20. In May 2011, UW Law Professor Patricia Kuszler, JD, MD, taught the same group of law students a follow-on course focusing on quality regulation in health care and interna­ tional medical research standards. She also taught similar material to nursing students. 21. A good source for links to this type of medical and bioethics literature is ETHNOMED, www.ethnomed.org (last visited June 6, 2012). This University of Washington website contains medical and cultural information about immigrant and refugee groups. 22. SALLY HUBAND ET AL., NURSING AND MIDWIFERY: A PRACTICAL APPROACH (2006). 2012] TEACHING HEAL Til LAW IN RURAL ETHIOPIA 491 faculty. Throughout the law school class, I frequently referred back to an exer­ cise from the first day. After a brief introductory lecture, I had the students break into small groups to discuss and prepare written responses to two questions without doing any outside research. I told them that the group members did not need to all agree on their responses. First: regarding health care or health care law, what does Ethiopia or the Oromia region do well? Second: what aspect of health care in Ethiopia would benefit from more or different regulation? In response to the question as to what Ethiopia or the Oromia region does well, many of the groups listed the use of health extension workers. Ethiopia has been recognized for extensive and effective use of health ex­ tension workers, generally women from the community who receive a year's training in basic primary health care needs.23 Other common re­ sponses included: mainstreaming HIV I AIDS treatment; constitutional recognition of a right to live in a healthy environment; expanded vaccina­ tion services; abortion laws; and improved maternal care. In response to the question as to what aspect of health care would ben­ efit from more or different regulation, the most common response was bet­ ter regulation of the quality of health care providers, including traditional medicine practitioners. Use of traditional treatments is common in Ethio­ pia, particularly in rural areas, and sometimes raises concern about safety and efficacy?4 Other common responses included: greater access to pri­ mary care; prohibition on harmful practices such as female genital cutting; stricter abortion laws;25 more rural health care facilities; and effective regu­ lation of environmental impacts on health. On their written responses to these questions, I asked the students to write the names of each member of the group that developed them. Where the responses tied into the topic of a subsequent class session, I was then able to ask specific students to elaborate. This technique seemed to encour­ age students to speak up (and also to help me better pronounce Ethiopian names). A similar exercise with the nursing students worked much less well. With the nursing students, I did this as an individual, not group exer­ cise; and I made the mistake of telling them in advance that I would not be This textbook is specifically designed for use in low-income countries. 23. See, e.g .• Wairagala Wakabi, Extension Workers Drive Ethiopia's Primary Health Care, 312 LANCET 880 (2008). The head of the U.S. and U.K. governments' aid programs have recognized the Ethiopian Health Extension Program as offering potentially "game changing" lessons in the fight against international poverty. See Press Release, Embassy of the United States: Addis Ababa. Ethiopia. International development leaders hail Ethiopian health extension program (Sept. 21, 2011), available at http:l/ethiopia.usembassy.gov/pr- 2011/international-development-leaders-hail-ethiopian-health-extension-program-september- 21-2012.html. 24. See, e.g., Richard M. Hodes. Cross-cultural Medicine and Diverse Health Beliefs: Ethiopians Abroad, 166 W. J. MED. 29,29 (1997). 25. The prominence of "abortion laws" as a response to both questions probably was related to an on-campus debate on the topic that was scheduled for the following week. 492 INDIANA HEALTH LAW REVIEW [Vol. 9:2 grading their responses. Most of the law students, I later learned, had as­ sumed that this was a graded assignment. N. SHANBAUG AND MEDICAL DECISION-MAKING One challenge in teaching about legal issues arising in the context of medical decision-making is that many of the prominent cases and statutes have arisen in regions with extensive medical resources and a significant cultural focus on individual autonomy?6 How relevant is that body of law in regions with limited medical resources? How applicable is it to regions with a broader focus on family or group affiliations? As health systems expand to provide a higher level of care to more people, many questions are likely to gain prominence: to what information are patients entitled?; if a patient lacks decisional capacity, who should decide?; when may medical care be withheld or withdrawn?; is physician-hastened death ever appropri­ ate?27 Any legal resolution of these questions is sure to be influenced by the cultural and medical context in which they arise. Fortuitously, a few weeks before my Haramaya law class began, In­ dia's Supreme Court handed down its decision in the publicly prominent end-of-life case involving Arona Shanbaug.28 The Court begins its opinion with the statement: "we feel like a ship in an uncharted sea, seeking some guidance by the light thrown by legislations and judicial pronouncements of foreign countries[.]"29 This 110-page opinion includes a survey of cases and statutes from several jurisdictions on patients' rights of self­ determination, surrogate decision-making, withdrawal of care, physician­ assisted death, and active euthanasia. It explicitly considers their applica­ bility in India's cultural and legal context. The Shanbaug case includes a compelling factual background. In 1973, while working as a nurse at King Edward Memorial Hospital (KEM) in Mumbai, Ms. Shanbaug was brutally assaulted and strangled with a metal dog leash by "a sweeper" whom she had chastised for stealing food intend­ ed for the stray dogs utilized in the hospital's dog lab.30 Ms. Shanbaug sus- 26. See Robert H. Blank, End-of-Life Decision Making Across Cultures, 39 J.L. MED. & Ennes 201 (20 11) (discussing limitations of the current focus on "western practices and values" and summarizing findings of a study of end-of-life policies in twelve countries, in­ cluding Kenya and India). 27. See, e.g., id. at 211 (discussing the "surge in requests for assisted suicide because of the AIDS epidemic" in Kenya). 28. In January 2012, a number of news reports from India were still available on-line. See, e.g., Aruna Shanbaug case: Supreme Court rejects euthanasia plea, NDTV, http://www .ndtv .com/article/india/aruna-shanbaug-case-supreme-court-rejects-euthanasia­ plea-89894 (last updated Mar. 7, 2011) (reporting decision and showing nurses' reaction in streets around the hospital where Ms. Shanbaug resides). 29. Shanbaug v. Union of India, Writ Petition (Criminal) 115 (2009), slip op. at 2 (In­ dia Mar. 7, 2011), available at http://judis.nic.inlsupremecourtlchejudis.asp. 30. ld. at 2-3. 2012] TEACHING HEALTH LAW IN RURAL ETHIOPIA 493 tained severe brain damage. She has been largely unresponsive and almost completely paralyzed for nearly forty years, occupying the same bed all the while at KEM Hospital. Based on testimony from a team of three Court· appointed doctors, the Court concluded that she meets the key criteria for being in a persistent vegetative state.31 The KEM staff is described in the opinion as devoted to her care. All the student nurses are introduced to her and told that "she was one ofus."32 The independent physicians' report cites as evidence of exceptional nursing care the fact that in thirty.eight years Ms. Shanbaug has not had even a sin· gle bed sore.33 She is painstakingly spoon·fed mashed food, though in 2010, while she recovered from malaria, a naso.gastric tube was also used.34 Pinky Virani, a right·to.die activist who wrote a book about Shan· baug's situation, petitioned for an end to the feedings, arguing that Ms. Shanbaug is ''virtually a dead person" and that not letting her "die peaceful­ ly" is causing her unnecessary pain and violating her right to dignity.35 Ms. Shanbaug' s family has not been involved in decades and declined to partic­ ipate in the case. 36 KEM strongly objected, arguing that its staff is effec­ tively her family, and they want to keep caring for her. 37 In resolving the case, the Court looked not only to Indian law, but al­ so to that of other jurisdictions, predominantly in high-resource countries.38 For example, it considers the scope of patients' rights to consent to medical care and to refuse care, referencing, as do so many U.S. cases, Sch/oendorff v. Society of New York Hospita/.39 The Court goes on to consider the gen­ eral role of surrogate decision·makers where the patient lacks decisional capacity.40 It contrasts the "substituted judgment" standard favored in the · United States, with the "best interests of the patient" standard favored in other countries.41 Much of the decision concerns the legal and ethical dis­ tinction between "active euthanasia," or physician-hastened death, and ''passive euthanasia," or a withdrawal of life·sustaining care; India's stat- 31. Id. at 4. Citing conflicting evidence, the Supreme Court appointed a panel of three independent physicians to examine Ms. Shanbaug and file a written report. The Court then requested that the physicians provide a clarifying report explaining the first in non-medical terminology and also appear before them to answer questions and to screen a current DVD ofMs. Shanbaug. Id at5, 17. 32. Id. at9. 33. ld. at 8, 27. 34. /d.at10-11. 35. Id. at 3-4. 36. !d. at 24. 37. Id. at25-29. 38. See generally id For helpful background to India's law in this regard, see Sushila Rao, India and Euthanasia: The Poignant Case of Aruna Slumbaug, 19 MED. L. REv. 646 (2011). 39. Slumbaug, slip op. at 66,81 (citing Schloendorffv. Society ofNew York Hospital, 211 N.Y. 125 (1914)). 40. /d. at 24, 36-37. 41. ld. 494 INDIANA HEALTH LAW REVIEW (Vol. 9:2 utes and Constitution are parsed and contrasted with "death with dignity" legal· frameworks in the Netherlands, Washington State and elsewhere. 42 Pending enactment of a law by India's Parliament, the Court's opinion in Shanbaug allows "passive euthanasia" (withdrawal of medical care) from an incompetent patient in certain circumstances. Those circumstances in­ clude the irreversible nature of the patient's vegetative condition, and the court petition by an appropriate surrogate (typically close family, but possi .. bly a friend or physician) stating that continued treatment is not in the pa­ tient's best interest.43 The Shanbaug Court further requires review by independent medical experts and judicial approval. These procedural safe­ guards are "necessary in our country as we cannot rule out the possibility of mischief being done by relatives or others for inheriting the property of the patient.'744 The Court goes on to reference George Bernard Shaw's play "The Doctor's Dilemma" and Robin Cook's novel Coma45 in expressing its concern that a surrogate's decision to withdraw care might be impacted by India's substantial income variation, as well as ''the low ethical levels pre­ vailing in our society today and the rampant commercialization and corrup­ tion" that includes unscrupulous physicians.46 In the case at hand, the Court concluded, the appropriate surrogate is KEM, and its staff wishes to continue providing curative care (in the case of a malaria bout for example) and regular care (the feedings). Thus it denied the petition. 47 I assigned an edited version of the Shanbaug decision as the first as­ signment in my Haramaya Current Issues in Health Law Seminar. For the next several sessions, it became a touchstone for our discussions about pa­ tients' rights, the role of surrogates, and end..of-life decision-making. In one exercise, the students considered which of Ethiopia's civil and criminal codes would have any relevance to the case. They discussed the tension between legal standards supporting a patient's right to make informed med­ ical decisions and cultural values that disfavor direct sharing of bad medical news. In another exercise, the students reviewed general bioethics principles· and discussed how they were expressed by India's Supreme Court. One in­ teresting discussion centered on the role of culture in informing legal and practical standards as to who should speak for an incapacitated patient What is meant by "close family"? The students also considered the "best 42. Id at 45-87. 43. /d. at 99. 44. Id at 101. 45. Id at 102. For an interesting discussion of the Court's use ofliterary references, see Frank Pasquale, Why Narratives Do (and Should) Matter in Bioethics, HEALTH REFORM WATCH (Mar. l 0, 2011 ), http://www.healthreformwatch.com/2011/03/l 0/wby-narratives-do­ and-sbould-matter-in-bioethics/. 46. /d. at 101. 47. /d. at 99-100, 108. 2012] TEACHING HEAL Til LAW IN RURAL ETIIIOPIA 495 interest" of the patient as expressed in the cases cited by Shanbaug and how that standard or the "substituted judgment" standard could be applied to Ms. Shanbaug's situation.48 The students voiced thoughtfully mixed views on the equity issues raised by the case. Many expressed admiration of the exceptionally high level of nursing care Ms. Shanbaug received. Some of those students joined others in arguing that it was not a good use of resources in a country where. so many struggle to access basic care. Furthermore, for a typical In­ dian in her situation, wouldn't lack of access to hospitalization or inability to pay for its continuation be determining factors in her case? This question led to a lively discussion about the appropriateness of personal connections in facilitating medical treatment. Ms. Shanbaug has occupied a hospital bed for nearly forty years not because an explicit government policy or because of her great wealth but apparently because of a personal connection with the hospital nurses and their sense of obligation to her.49 The first of two required papers, due at the end of the second week, was about Shanbaug. This paper was to be no more than five pages and include three sections: issue; Ethiopian context; and assessment. For the issue section, students were to describe the main legal issues before the In­ dia Supreme Court and its resolution of those issues. Next they were to describe their understanding of the current state of these issues in Ethiopia, with reference to at least one source outside of the required readings. As specified in the syllabus, the students were free to work collaboratively to uncover these additional sources, which could be statutes, regulations, cas­ es, commentaries, health practice guides, medical journal notes, news arti­ cles or popular media depictions from Ethiopia or another Aftican country. Finally, they were to present their opinions about the Shanbaug case and its relevance or lack of relevance in Ethiopia. As to this last section, I was pleased to see a range of well-articulated views. In the middle section, the additional sources were not as illuminating or varied as I had hoped. Although I had deliberately allowed a range of sources, I had not anticipat­ ed the research challenges. The students had only a few days to do this re­ search, computer access is limited, and the Internet was down most of the time. Ethiopia's civil and criminal codes became the default additional source material. V. PEPFAR PAR1NERSHIP FRAMEWORKS AND POPULATION HEALTH For the second half of the Haramaya Law class, I planned to focus on 48. For a very good discussion of these and other comparative health law issues, see TIMOTIIY STOLTZFUS JOST, READINGS IN COMPARATIVE HEALTH LAW AND BIOETIHCS (2d ed. 2007). 49. Indeed, according to Rao, supra note 38, at 655, the KEM staff objected to efforts to move her elsewhere to free up the hospital bed. 496 INDIANA HEALTH LAW REVIEW [Vol. 9:2 the role of the law in promoting population health, ideally with some speci­ ficity as to Ethiopia. In a timely bit of symbiosis, in the fall of 2010 I was part of a multidisciplinary team from the University of Washington that was in the planning stages of a project related to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) in Africa.50 The project centers on the health policy reforms identified in PEPF AR Partnership Frameworks (PF).51 And in late October 2010, Ethiopia's PF was signed, setting up the possibility of problem-based learning related to some of its provisions. 52 As of January 2012, there are nineteen country-specific PFs and two regional PFs.53 Each PF begins with data about the country's health indica­ tors and health systems, both as to IDV/AIDS and also more generally. This section could be part of a short introductory summary for a health law course. The policy reforms detailed in these PFs include both specific and general proposals. Malawi's, for example, states that its Ministry of Health . "expects to ... chang[e] 'anonymous' reporting to 'confidential' reporting in order to permit a name-based referral system. "54 This sort of specific proposal lends itself to discussions about confidentiality, mandatory report­ ing rules, and roles of public health agencies, as well as processes for changing legally enforceable standards. Swaziland's includes a goal of "improv[ing] the status and rights of women, people living with mv and AIDS (PLWHA) and other vulnerable groups."55 This sort of general pro­ posal invites discussion about the · role of human rights and anti­ discrimination laws in promoting health. The PFs involve a number of common policy areas. These are human resources for health, mv testing and counseling, laboratory standards, or- 50. The project has since been funded as a cooperative endeavor with the Centers for Disease·control (CDC), the United States Agency for International Development (USAID) and Futures Group, a global health consulting firm. It aims to support the advancement of health-care related policy and law reforms identified in the PFs. As an initial phase of this multi-year project, in 2012 we will collaborate with in-country partners to host regional workshops focused on monitoring identified health policy reforms. 51. PEPFAR began in 2003. PEPFAR's 2008 reauthorization shifts the program's focus "from. an emergency response to promoting sustainable country programs." This se­ cond phase of PEPF AR includes Partnership Frameworks ("PFs"), "5-year joint strategic ftamework[s] for cooperation between the [United States government], the partner govern­ ment, and other partners to combat HIV/AIDS in the country through technical assistance and support for service delivery, policy reform, and coordinated financial commitments." Partnership Frameworks: Introduction, U.S. PRESIDENT'S EMERGENCY PLAN FOR AIDS R.ELmF, http://www.pepfar.gov/guidance/ftamework/1205 13.htm (last visited June 10, 2012). 52. Thanks to Amy Hagopian, Ph.D., for this suggestion. 53. For a current list, see Partnership Frameworks, U.S. PRESIDENT'S EMERGENCY PLAN FOR AIDS RELmF, http://www.pepfar.gov/ftameworks/index.htm (last visited June 10, 2012). 54. Partnership Framework Document to Support Implementation of the Malawi Na­ tional HIV and AIDS Response, U.S.-Malawi, May 18, 2009, at 6, available at http://www.pepfar.gov/ftameworks/malawil'mdex.htm. 55. Swaziland Partnership Framework on .HIV and AIDS 2009-2013, U.S.-Swaz., June 4, 2009, at 3, available at http://www.pepfar.gov/ftameworks/swaziland/index.htm. 2012] TEACHING HEALTH LAW IN RURAL ETHIOPIA 497 phans and vulnerable children, and nondiscrimination. These areas will not reflect the full gamut of public health law issues of importance to a country. But-if the PFs are to be meaningful-they should reflect country-specific areas of concern and possible change. For some PFs, there are now related Partnership Framework Imple­ mentation Plans that address issues such as prioritization, implementation options, barriers to change, and evaluation criteria. 56 Does a guideline need revising? A regulation adopted? A law enacted? Are there stakeholders with a particular interest or expertise in the area? Are there government agencies with particular responsibility? What are the barriers to change? How will priorities be identified? How will progress be monitored and evaluated? These issues and more can be addressed in the implementation plans. Taking a broader approach in an academic setting, the PFs and relat­ ed implementation plans lend themselves to consideration of the efficacy of legal enactments and international declarations in actually supporting health system and health status improvement. Ethiopia's PF includes proposed legal and policy reforms aimed at "addressing [Ethiopia's] mv epidemic, as well as [supporting the Ethiopi­ an government's] commitment to the broader health needs of its people."57 The reforms are grouped into four broad categories: prevention; quality care, treatment and support; health system; and health governance. An ex­ tensive course could be built around these topics. I assigned an edited version of Ethiopia's PF for use in four class ses­ sions and for the second paper. We began with the Ethiopia PF overview sections and considered generally how the HN I AIDS epidemic in Africa has impacted key areas of health law and policy. 58 In the following class, we considered goals of universal access to primary care and of a national insurance system as expressed in Ethiopia's PF.59 These topics were enliv­ ened by a discussion of how private payments enter into ostensibly free health care. A Tanzanian newspaper article provided the springboard by 56. Partnership Framework Implementation Plans, U.S. PREsiDENT'S EMERGENCY PLAN FOR AIDs RELIEF, http://www'.pepfar.gov/guidance/framework/120732.htm (last visited June 8, 2012). 57. SUMMARY OF THE HIV/AIDS PARTNERSHIP FRAMEWORK Wl1ll THE GoVERNMENT OF THE FEDERAL DEMOCRATIC REPuBLic OF ETIHOPIA. U.S. PRESIDENT'S EMERGENCY PLAN FOR AIDS RELIEF l, http://www.pepfar.gov/documents/organization/154220.pdf (last visited June 4, 2012). 58. For a helpful overview in this regard, see Peri H. Alkas & Wayne X. Shandera, HJV and AIDS in Africa: African Policies in Response to AIDS in Relation to Various Na­ tional Legal Traditions, 17 J.L. MEo. 527, 527-29,538-43 (1996) (discussing laws of more than a dozen countries, including Ethiopia). 59. Regarding health insurance systems in other African countries, see generally Joio L. Carapinha et al., Health Insurance Systems in Five Sub-Saharan African Countries: Med­ icine Benefits and Data for Decision Malcing, 99 HEALrn PoL'Y 193 (2011) (discussing characteristics of different types of health insurance systems and comparing programs in Ghana, Kenya, Nigeria, Tanzania, and Uganda). 498 INDIANA HEALTH LAW REVIEW [Vol. 9:2 citing a study that bribery was common in thatcountry'-s hospitals.60 Sever­ al students related anecdotes that for non-emergency care or for a family member to stay with a hospitalized patient, payment might be expected, if only to the facility's guard. While anecdotes are low-grade data, this dis­ cussion did help focus consideration on the role of the law in ensuring '