Viewpoint
Global Health Service Partnership: building health professional leadership Vanessa B Kerry, Fitzhugh Mullan Lancet 2014; 383: 1688–91 Published Online December 18, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61683-9 Seed Global Health, Boston, MA, USA (V B Kerry MD, Prof F Mullan MD); Center for Global Health, and Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA (V B Kerry); Harvard Medical School, Boston, MA, USA (V B Kerry); George Washington University School of Public Health and Health Services, Washington, DC, USA (Prof F Mullan); and Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA (Prof F Mullan) Correspondence to: Dr Vanessa B Kerry, Seed Global Health, Boston, MA 02114,USA [email protected] For more on the Global Health Service Partnership see http:// www.peacecorps.gov/response/ globalhealth/
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Shortages of nurses, doctors, and health professionals in resource-poor countries challenge the success of many health initiatives and health-system strengthening. In many of these countries, medical and nursing schools are few and severely short of faculty, limiting their capacity to scale-up and increase the number of skilled graduates and professionals to support the health system. In an effort to address this problem, the US Peace Corps has partnered with Seed Global Health, a non-profit organisation with expertise in education for health professions, to launch an innovative new programme that sends faculty to medical and nursing schools in under-resourced settings. The programme, called the Global Health Service Partnership, placed 31 American clinical faculty—dedicated educators— in medical and nursing schools in Tanzania, Uganda, and Malawi in July, 2013. In collaboration with the schools, the partnership hopes to help to train new health professionals and to retain those already working. It is partly funded by the President’s Emergency Plan For AIDS Relief and is augmented by private philanthropy. The programme is expected to increase the numbers of faculty they place in medical and nursing schools, the countries involved, and the health disciplines included. The Global Health Service Partnership is a targeted response to a well documented and tenacious global crisis in global health workforce that was dramatically exacerbated by the HIV/AIDS pandemic in many parts of the world. Recent efforts to stem pandemics such as those of HIV and malaria, have helped to uncover an underlying, but profound issue; too few health professionals are available to tackle the health needs of populations in which disease burden is highest.1 Additionally, trained professionals from a mix of specialties are needed to address the long-term health needs of a country. A two-fold approach is needed to address these problems: more professionals should be trained and more should practice where the health problems are most pronounced. National governments, donors, and health leaders now understand that the health-care workforce is crucial to strengthen health systems, deliver care, tackle epidemics such as HIV, and address the rapidly growing challenges for chronic disease management. The President’s Emergency Plan For AIDS Relief includes a focus on training new healthcare workers,2 as do the plans of several other countries responding to the same concern. For example, Ethiopia has substantially increased the numbers of health profession schools and students.3 The Malawi Government has devoted substantial proportions of their national health budget to its health workforce,4 and Mozambique has opened two new medical schools,
which will eventually triple the number of medical graduates.5 Expansion of human resources will not only need increased numbers of staff, but also an appropriate mix of health professionals and their specialties. A recent report from South Sudan6 outlined a full range of national specialty needs, showing the absence of advanced medical training in the country. In recognition, countries are increasingly working to develop more specific training for clinical expertise and leadership.7,8 Shortage of faculty in many resource-poor settings limits their ability to expand education, graduate basic medical and nurse clinicians, and to produce specialists and health system leaders.9 This shortcoming has been shown by a recent commission of professional medical education, which noted that health professional education has faltered because of burgeoning health challenges, and that faculty are essential to the investment of future health dividends through training of the next generation of health professionals.10 Sustainability and selfsufficiency of a country’s health systems will depend on building a pipeline of new doctors and nurses trained to continue teaching of future generations. But faculty and specialist shortages in resource-poor settings are exacerbated by emigration of graduates to countries in North America, Europe, and the Gulf region.11 In addition to job insecurity, safety, and low salaries, emigration is affected by large teaching loads, lack of professional development opportunities, and scarce career options.1,12–16 Any meaningful response to increase health leadership and promote a sustainable pipeline of highly trained physicians, nurses, and other health professionals will need broad investments in professional opportunity and faculty.17–19 The Global Health Service Partnership support for African health professional faculties is intended to improve the educational environments of medical and nursing schools. Improvements in degree training for nurses and basic and post-graduate training for medical doctors will help to address the ubiquitous need for more practitioners and faculty. Global Health Service Partnership doctors and nurses will bring with them experiences and links that can be of assistance to colleagues in host countries, such as innovative teaching methods, clinical guidelines, treatment protocols, and interprofessional collaboration. The Global Health Service Partnership aims to contribute to a pipeline of health professionals that are invested in the health education systems of their countries and focused on the disease burden affecting their population. After a review of factors, including the capacity of Peace Corps posts, other partners in the countries, and the interest and commitment of host governments, the www.thelancet.com Vol 383 May 10, 2014
Viewpoint
programme chose Tanzania, Malawi, and Uganda, to launch in July, 2013. Peace Corps and Seed Global Health have worked with each country’s Ministry of Health, Ministry of Education, and their medical and nursing councils in site selection and advanced planning for future years. The Global Health Service Partnership aims to help to address national training needs and human resource gaps, as determined by the countries themselves. Guided by consultations with the country, sites were invited to apply for Global Health Service Partnership volunteers. Placements were made on the basis of site-specific needs, support available, and ministry priorities. The schools in the three countries requested staff from many medical and nursing specialties (appendix). In an effort to focus recruitment in the first year, Global Health Service Partnership targeted specific medical and nursing disciplines. Medical faculty recruitment included those qualified in internal medicine, paediatrics, obstetrics and gynaecology, surgery, anaesthesia, psychiatry, and family medicine. Nursing faculty included those qualified in comprehensive nursing, midwifery, psychiatry, critical care, surgery, internal medicine, and paediatrics. Physicians must be board-eligible or boardcertified in their specialty (fully trained) with an active US licence. Nurses are required to have a Bachelor of Science in Nursing, plus a higher degree and at least 3 years of clinical experience. Volunteers are assessed by written applications and interviews by both the Peace Corps and Seed, and the curricula vitae of some volunteers were sent to locations for review and approval. Although there was little publicity for the programme because of its start-up nature, 70 medical and 100 nursing applications were received, from which 15 nurses and 16 physicians were chosen. Overall, the candidates who applied included 27 (39%) physicians who were recent residency graduates, and 34 (49%) physicians and 38 (38%) nurses with more than 8 years of clinical and teaching experience. In the group were 39 former Peace Corps Volunteers, five people with nursing doctorates, 15 people with Master of Public Health degrees, and 10 certified nurse midwives. Of the 31 volunteers who were chosen, ten had more than 25 years of clinical experience, seven had between 5 and 15 years of clinical experience, 14 had less than 5 years of clinical experience. The Global Health Service Partnership nurses and physicians are assigned for 1 year posts as faculty members and have a designated faculty counterpart. Their tasks are defined in an individual memorandum of understanding on the basis of the school’s need and the individual’s capabilities. Generally, physicians taking part in the Global Health Service Partnership faculty teach beside the host-country faculty at the medical student and the postgraduate levels. They take on teaching responsibilities, including clinical instruction, ward rounds, and didactic sessions. They engage in patient care as part of their educational work and might provide conferences about basic science, clinical science, www.thelancet.com Vol 383 May 10, 2014
and public health. Nursing faculty lecture and oversee inservice education, working closely with the institution to develop curricula and clinical modules, provide access to the latest research in specialty areas, and establish course and clinical goals. The settings vary from internationally known universities such as the Muhimbili University of Health and Allied Sciences in Tanzania and the College of Medicine of the University of Malawi, to several rural schools training nurses and clinical officers. The postings are school-based, but the nursing and medical faculty might work in community or satellite location depending on the curriculum and the needs of the school. The medical volunteers take part in a 2 week orientation in Washington DC, USA, followed by 2 weeks of in-country orientation that covers background on the countries, details of health and education systems, an overview of tropical health, and discussions about culture, working, and teaching in resource-poor settings. Volunteers also receive basic language training as appropriate. At the sessions in Africa, staff meet their in-country counterparts who will provide support and assistance with integration into the faculty and community. The physician and nurse faculty serve as Peace Corps volunteers, with the US federal agency providing support for living, travel, logistics, benefits, professional resource needs, and medical liability. Participating sites are responsible for housing for the volunteers. Seed Global Health provides technical support to the A
See Online for appendix
B
Figure: Model from the Global Health Service Partnership for sustainable human resource education (A) The training model; every Global Health Service Partnership educator reaches a population of new clinicians who, in turn, become potential educators. (B) Population impact model; every clinician trained by a Global Health Service Partnership educator helps to offset shortages of health professionals.
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For more on the partnership with President’s Emergency Plan for AIDS Relief see http:// www.pepfar.gov/partnerships/ initiatives/nepi/
For more on the Medical Education Partnership Initiative see http://www. mepinetwork.org/ For more on Human Resources for Health Rwanda see http:// hrhconsortium.moh.gov.rw/
volunteers and their counterparts in their professional and clinical tasks. Support includes back-up by Seed and Peace Corps staff with links to specialty and electronic resources in the USA and elsewhere. Country volunteers meet at several points through the year, and all the volunteers will convene once a year. To help to ensure that health professional volunteers are able to pay educational or professional debts, Seed provides loan repayment of up to US$30 000 per year of service. This payment is funded through independent private philanthropy, raised by Seed. The short-term goal of the Global Health Service Partnership is to help to address faculty shortages at partner schools and to assist in educational innovations and scale-ups that are occurring in many medical and nursing schools. In the longer-term, the Global Health Service Partnership is hoped to help to support the growth of core in-country faculty. The particular intent of faculty educational support is to serve as a so-called force multiplier, helping to scale-up teaching capacity, increase clinical personnel, and, over time, strengthen the medical, nursing, and health-education systems in the partner countries (figure). The Global Health Service Partnership is in its infancy, and has started in 11 sites in three countries in subSaharan Africa (table). The targeted effect will occur after time, with the graduation of more students and residents. The Global Health Service Partnership must be iterative, and learn from events in its first years to improve its model. The partnership will surely be guided by the experiences of many African medical and nursing schools with expatriate faculty.16,20–22 Additionally, although a small start-up, the Global Health Service Partnership is positioned to make substantial contributions in the
future because of several features: the sponsorship of the Peace Corps with financial backing from President’s Emergency Plan for AIDS Relief, Seed’s success in raising private funds, US faculty’s enormous interest in working abroad as teachers, and the demand from countries and their institutions for the partnership, which well exceeds current capacity. The programme is in regular communication with US-sponsored scale-up programmes such as the Medical Education Partnership Initiative and the Nursing Education Partnership Initiative, and with developing programmes such as Human Resources for Health Rwanda. Global Health Service Partnership works closely with national governments and human resources for health planners in all partner countries. How will we know what kind of effect the Global Health Service Partnership has had? Monitoring and evaluation will be important functions to guide growth, improve impact and retention, and strengthen the programme to ensure effectiveness. To achieve this goal, the Peace Corps, Seed, and in-country partners will work collaboratively to do assessments. We will specifically align our monitoring and evaluation with similar programmes to understand successes and failures on a broader scale. Many challenges lie ahead for the Global Health Service Partnership, including how to assist with the infrastructure needs of the sites and how to help to promote strategies for retention of trainees and current faculty. After the current model is piloted, the programme intends to build on its effect by increasing the number of volunteers, countries served, and health professions involved. National leaders and international authorities have pinpointed that the need for more faculty to support medical and nursing schools in resource-poor countries is a
Region or district
MD
RN
Total
Specialty
Blantyre district, Lilongwe district
5
0
5
Psychiatry, obstetrics and gynaecology (2), internal medicine, paediatrics
Malawi University of Malawi, College of Medicine Mzuzu University
Mzimba district
0
2
2
Paediatrics, comprehensive
Kamuzu College of Nursing
Blantyre district, Lilongwe district
0
4
4
Midwifery, paediatrics, comprehensive nursing and infectious disease, mental health
Gulu University
Gulu district
3
0
3
Paediatrics, internal medicine (2)
Lira School of Nursing
Lira district
0
2
2
Comprehensive nursing, public health and mental health
Mbarara University of Science and Technology
Mbarara district
3
3
6
MD: paediatrics, internal medicine, infectious disease; RN: surgical, comprehensive nursing (2)
Uganda
Tanzania Muhimbili University of Health and Allied Sciences Dar es Salaam region
2
0
2
Anaesthesiology, cardiology
MVUMI Clinical Officers Training Center
Dodoma region
1
0
1
Family medicine
Mirembe School of Nursing
Dodoma region
0
2
2
Midwifery, comprehensive nursing
Bugando Medical Center
Mwanza region
2
2
4
MD: obstetrics and gynaecology, paediatrics and internal medicine; RN: women’s health, comprehensive nursing
MD=doctor of medicine. RN=registered nurse.
Table: Number and types of volunteers sent to each site arranged by location and country
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Viewpoint
major bottleneck to the strengthening of health systems. The Global Health Service Partnership focuses on medical and nursing education as crucial to help to build sustainable health systems. We hope that the work produced through the partnership will help to highlight the need for health leadership and faculty, and show that educational investments have long-lasting benefits for students, faculty, and health systems. Contributors VBK did the literature search, data collection, data analysis and interpretation, constructed the figures and tables, and contributed to the preparation of the Viewpoint. FM contributed to the preparation of the Viewpoint. Conflicts of interest VBK is the Chief Executive Officer of Seed Global Health (formerly Global Health Service Corps). FM is the Founding Chairman of the Board of Trustees for Seed Global Health, and the Murdock Head Professor of Medicine and Health Policy at George Washington University. Funding for the Global Health Service Partnership was provided by President’s Emergency Plan for AIDS Relief, the Engelhard Foundation, Draper Richards Kaplan Foundation, Pfizer Foundation, and Goldman Sachs Gives. Acknowledgments We thank Jennifer Goldsmith (Seed Global Health, Boston, MA, USA) for her assistance in finalising the figure, table, and appendix. References 1 WHO. The world health report 2006: working together for health. Geneva: World Health Organization, 2006. http://www.who.int/ whr/2006/en/ (accessed Jan 19, 2013). 2 PEPFAR. Health Systems Strengthening. Washington, DC: Presidents Emergency Programme for AIDS Relief, 2013. http:// www.pepfar.gov/about/138338.htm (accessed Jan 24, 2013). 3 Ethiopia: Surge of doctors to strengthen health system. http:// nazret.com/blog/index.php/2012/08/16/ethiopia-surge-of-doctorsto-strengthen-health-system (accessed April 1, 2013). 4 Malawi Health Equity Network. 2010/2011 Health Sector Budget Analysis. http://www.africawindmill.org/Health-BudgetAnalysis_2010_v4.pdf (accessed April 1, 2013). 5 PEPFAR. The Universidade Eduardo Mondlane, UCSD Medical Education Partnership. http://www.pepfar.gov/partnerships/ initiatives/mepi/network/mozambique/index.htm (accessed April 1, 2013). 6 Achiek M, Lado D. Mapping the specialist medical workforce for Southern Sudan: devising ways for capacity building. South Sudan Medical Journal 2010; 3. http://www. southsudanmedicaljournal.com/assets/files/Journals/vol_3_ iss_2_may_10/ssudanworkforce.pdf (accessed Jan 21, 2013).
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8
9 10
11 12
13 14 15
16
17
18
19 20
21
22
Adetuyibi A. Specialist training and medical research in developing countries of tropical Africa: a case for the establishment of postgraduate medical schools. Med Educ 1977; 11: 355–57. Kerry V, Kabakyenga J, Maling S, Ayanda N, Gore A, Bangsberg DR. Clinical specialist training fellowship: partnering to meet the priorities of African training institutions for medical leadership. Consortium of Universities for Global Health Annual Conference; Washington, DC; March 14–16, 2013. Mullan F, Frehywot S, Omaswa F, et al. Medical schools in sub-Saharan Africa. Lancet 2011; 377: 1113–21. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010; 376: 1923–58. Mullan F. The metrics of the physician brain drain. N Engl J Med 2005; 353: 1810–18. Awases M, Gbary A, Nyoni J, Chatora R. Migration of health professionals in six countries: a synthesis report. Geneva: World Health Organization Regional Office for Africa, 2003. http://www. hrhresourcecenter.org/node/61 (accessed Jan 19, 2013). Bezuidenhout M, Joubert G, Hiemstra L, Struwig M. Reasons for doctor migration from South Africa. SA Fam Pract 2009; 51: 211–15. Bundred PE, Levitt C. Medical migration: who are the real losers? Lancet 2000; 356: 245–46. Muula AS. Is there any solution to the “brain drain” of health professionals and knowledge from Africa? Croat Med J 2005; 46: 21–29. Kerry VB, Ndung’u T, Walensky RP, Lee PT, Kayanja VF, Bangsberg DR. Managing the demand for global health education. PLoS Med 2011; 8: e1001118. IANPHI. International Institute for Public Health Institutes home page. Helsinki and Atlanta: IANPHI, 2013. www.ianphi.org (accessed Jan 21, 2013). Wellcome Trust. Global Health Research. London: Wellcome Trust, 2013. http://www.wellcome.ac.uk/funding/biomedical-science/ funding-schemes/strategic-awards-and-initiatives/wtvm055107.htm (accessed Jan 19, 2013). Third World Academy of Sciences. Building scientific capacity: a TWAS perspective. Trieste: Third World Academy of Sciences, 2011. Einterz RM, Kimaiyo S, Mengech HN, et al. Responding to the HIV pandemic: the power of an academic medical partnership. Acad Med 2007; 82: 812–18. Pallangyo K, Debas HT, Lyamuya E, et al. Partnering on education for health: Muhimbili University of Health and Allied Sciences and the University of California San Francisco. J Public Health Policy 2012; 33 (suppl): S13–22. Celletti F, Reynolds TA, Wright A, Stoertz A, Dayrit M. Educating a new generation of doctors to improve the health of populations in low- and middle-income countries. PLoS Med 2011; 8: e1001108.
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Global Health Service Partnership: building health professional leadership Vanessa B Kerry, Fitzhugh Mullan Lancet 2014; 383: 1688–91 Published Online December 18, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61683-9 Seed Global Health, Boston, MA, USA (V B Kerry MD, Prof F Mullan MD); Center for Global Health, and Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA (V B Kerry); Harvard Medical School, Boston, MA, USA (V B Kerry); George Washington University School of Public Health and Health Services, Washington, DC, USA (Prof F Mullan); and Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA (Prof F Mullan) Correspondence to: Dr Vanessa B Kerry, Seed Global Health, Boston, MA 02114,USA [email protected] For more on the Global Health Service Partnership see http:// www.peacecorps.gov/response/ globalhealth/
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Shortages of nurses, doctors, and health professionals in resource-poor countries challenge the success of many health initiatives and health-system strengthening. In many of these countries, medical and nursing schools are few and severely short of faculty, limiting their capacity to scale-up and increase the number of skilled graduates and professionals to support the health system. In an effort to address this problem, the US Peace Corps has partnered with Seed Global Health, a non-profit organisation with expertise in education for health professions, to launch an innovative new programme that sends faculty to medical and nursing schools in under-resourced settings. The programme, called the Global Health Service Partnership, placed 31 American clinical faculty—dedicated educators— in medical and nursing schools in Tanzania, Uganda, and Malawi in July, 2013. In collaboration with the schools, the partnership hopes to help to train new health professionals and to retain those already working. It is partly funded by the President’s Emergency Plan For AIDS Relief and is augmented by private philanthropy. The programme is expected to increase the numbers of faculty they place in medical and nursing schools, the countries involved, and the health disciplines included. The Global Health Service Partnership is a targeted response to a well documented and tenacious global crisis in global health workforce that was dramatically exacerbated by the HIV/AIDS pandemic in many parts of the world. Recent efforts to stem pandemics such as those of HIV and malaria, have helped to uncover an underlying, but profound issue; too few health professionals are available to tackle the health needs of populations in which disease burden is highest.1 Additionally, trained professionals from a mix of specialties are needed to address the long-term health needs of a country. A two-fold approach is needed to address these problems: more professionals should be trained and more should practice where the health problems are most pronounced. National governments, donors, and health leaders now understand that the health-care workforce is crucial to strengthen health systems, deliver care, tackle epidemics such as HIV, and address the rapidly growing challenges for chronic disease management. The President’s Emergency Plan For AIDS Relief includes a focus on training new healthcare workers,2 as do the plans of several other countries responding to the same concern. For example, Ethiopia has substantially increased the numbers of health profession schools and students.3 The Malawi Government has devoted substantial proportions of their national health budget to its health workforce,4 and Mozambique has opened two new medical schools,
which will eventually triple the number of medical graduates.5 Expansion of human resources will not only need increased numbers of staff, but also an appropriate mix of health professionals and their specialties. A recent report from South Sudan6 outlined a full range of national specialty needs, showing the absence of advanced medical training in the country. In recognition, countries are increasingly working to develop more specific training for clinical expertise and leadership.7,8 Shortage of faculty in many resource-poor settings limits their ability to expand education, graduate basic medical and nurse clinicians, and to produce specialists and health system leaders.9 This shortcoming has been shown by a recent commission of professional medical education, which noted that health professional education has faltered because of burgeoning health challenges, and that faculty are essential to the investment of future health dividends through training of the next generation of health professionals.10 Sustainability and selfsufficiency of a country’s health systems will depend on building a pipeline of new doctors and nurses trained to continue teaching of future generations. But faculty and specialist shortages in resource-poor settings are exacerbated by emigration of graduates to countries in North America, Europe, and the Gulf region.11 In addition to job insecurity, safety, and low salaries, emigration is affected by large teaching loads, lack of professional development opportunities, and scarce career options.1,12–16 Any meaningful response to increase health leadership and promote a sustainable pipeline of highly trained physicians, nurses, and other health professionals will need broad investments in professional opportunity and faculty.17–19 The Global Health Service Partnership support for African health professional faculties is intended to improve the educational environments of medical and nursing schools. Improvements in degree training for nurses and basic and post-graduate training for medical doctors will help to address the ubiquitous need for more practitioners and faculty. Global Health Service Partnership doctors and nurses will bring with them experiences and links that can be of assistance to colleagues in host countries, such as innovative teaching methods, clinical guidelines, treatment protocols, and interprofessional collaboration. The Global Health Service Partnership aims to contribute to a pipeline of health professionals that are invested in the health education systems of their countries and focused on the disease burden affecting their population. After a review of factors, including the capacity of Peace Corps posts, other partners in the countries, and the interest and commitment of host governments, the www.thelancet.com Vol 383 May 10, 2014
Viewpoint
programme chose Tanzania, Malawi, and Uganda, to launch in July, 2013. Peace Corps and Seed Global Health have worked with each country’s Ministry of Health, Ministry of Education, and their medical and nursing councils in site selection and advanced planning for future years. The Global Health Service Partnership aims to help to address national training needs and human resource gaps, as determined by the countries themselves. Guided by consultations with the country, sites were invited to apply for Global Health Service Partnership volunteers. Placements were made on the basis of site-specific needs, support available, and ministry priorities. The schools in the three countries requested staff from many medical and nursing specialties (appendix). In an effort to focus recruitment in the first year, Global Health Service Partnership targeted specific medical and nursing disciplines. Medical faculty recruitment included those qualified in internal medicine, paediatrics, obstetrics and gynaecology, surgery, anaesthesia, psychiatry, and family medicine. Nursing faculty included those qualified in comprehensive nursing, midwifery, psychiatry, critical care, surgery, internal medicine, and paediatrics. Physicians must be board-eligible or boardcertified in their specialty (fully trained) with an active US licence. Nurses are required to have a Bachelor of Science in Nursing, plus a higher degree and at least 3 years of clinical experience. Volunteers are assessed by written applications and interviews by both the Peace Corps and Seed, and the curricula vitae of some volunteers were sent to locations for review and approval. Although there was little publicity for the programme because of its start-up nature, 70 medical and 100 nursing applications were received, from which 15 nurses and 16 physicians were chosen. Overall, the candidates who applied included 27 (39%) physicians who were recent residency graduates, and 34 (49%) physicians and 38 (38%) nurses with more than 8 years of clinical and teaching experience. In the group were 39 former Peace Corps Volunteers, five people with nursing doctorates, 15 people with Master of Public Health degrees, and 10 certified nurse midwives. Of the 31 volunteers who were chosen, ten had more than 25 years of clinical experience, seven had between 5 and 15 years of clinical experience, 14 had less than 5 years of clinical experience. The Global Health Service Partnership nurses and physicians are assigned for 1 year posts as faculty members and have a designated faculty counterpart. Their tasks are defined in an individual memorandum of understanding on the basis of the school’s need and the individual’s capabilities. Generally, physicians taking part in the Global Health Service Partnership faculty teach beside the host-country faculty at the medical student and the postgraduate levels. They take on teaching responsibilities, including clinical instruction, ward rounds, and didactic sessions. They engage in patient care as part of their educational work and might provide conferences about basic science, clinical science, www.thelancet.com Vol 383 May 10, 2014
and public health. Nursing faculty lecture and oversee inservice education, working closely with the institution to develop curricula and clinical modules, provide access to the latest research in specialty areas, and establish course and clinical goals. The settings vary from internationally known universities such as the Muhimbili University of Health and Allied Sciences in Tanzania and the College of Medicine of the University of Malawi, to several rural schools training nurses and clinical officers. The postings are school-based, but the nursing and medical faculty might work in community or satellite location depending on the curriculum and the needs of the school. The medical volunteers take part in a 2 week orientation in Washington DC, USA, followed by 2 weeks of in-country orientation that covers background on the countries, details of health and education systems, an overview of tropical health, and discussions about culture, working, and teaching in resource-poor settings. Volunteers also receive basic language training as appropriate. At the sessions in Africa, staff meet their in-country counterparts who will provide support and assistance with integration into the faculty and community. The physician and nurse faculty serve as Peace Corps volunteers, with the US federal agency providing support for living, travel, logistics, benefits, professional resource needs, and medical liability. Participating sites are responsible for housing for the volunteers. Seed Global Health provides technical support to the A
See Online for appendix
B
Figure: Model from the Global Health Service Partnership for sustainable human resource education (A) The training model; every Global Health Service Partnership educator reaches a population of new clinicians who, in turn, become potential educators. (B) Population impact model; every clinician trained by a Global Health Service Partnership educator helps to offset shortages of health professionals.
1689
Viewpoint
For more on the partnership with President’s Emergency Plan for AIDS Relief see http:// www.pepfar.gov/partnerships/ initiatives/nepi/
For more on the Medical Education Partnership Initiative see http://www. mepinetwork.org/ For more on Human Resources for Health Rwanda see http:// hrhconsortium.moh.gov.rw/
volunteers and their counterparts in their professional and clinical tasks. Support includes back-up by Seed and Peace Corps staff with links to specialty and electronic resources in the USA and elsewhere. Country volunteers meet at several points through the year, and all the volunteers will convene once a year. To help to ensure that health professional volunteers are able to pay educational or professional debts, Seed provides loan repayment of up to US$30 000 per year of service. This payment is funded through independent private philanthropy, raised by Seed. The short-term goal of the Global Health Service Partnership is to help to address faculty shortages at partner schools and to assist in educational innovations and scale-ups that are occurring in many medical and nursing schools. In the longer-term, the Global Health Service Partnership is hoped to help to support the growth of core in-country faculty. The particular intent of faculty educational support is to serve as a so-called force multiplier, helping to scale-up teaching capacity, increase clinical personnel, and, over time, strengthen the medical, nursing, and health-education systems in the partner countries (figure). The Global Health Service Partnership is in its infancy, and has started in 11 sites in three countries in subSaharan Africa (table). The targeted effect will occur after time, with the graduation of more students and residents. The Global Health Service Partnership must be iterative, and learn from events in its first years to improve its model. The partnership will surely be guided by the experiences of many African medical and nursing schools with expatriate faculty.16,20–22 Additionally, although a small start-up, the Global Health Service Partnership is positioned to make substantial contributions in the
future because of several features: the sponsorship of the Peace Corps with financial backing from President’s Emergency Plan for AIDS Relief, Seed’s success in raising private funds, US faculty’s enormous interest in working abroad as teachers, and the demand from countries and their institutions for the partnership, which well exceeds current capacity. The programme is in regular communication with US-sponsored scale-up programmes such as the Medical Education Partnership Initiative and the Nursing Education Partnership Initiative, and with developing programmes such as Human Resources for Health Rwanda. Global Health Service Partnership works closely with national governments and human resources for health planners in all partner countries. How will we know what kind of effect the Global Health Service Partnership has had? Monitoring and evaluation will be important functions to guide growth, improve impact and retention, and strengthen the programme to ensure effectiveness. To achieve this goal, the Peace Corps, Seed, and in-country partners will work collaboratively to do assessments. We will specifically align our monitoring and evaluation with similar programmes to understand successes and failures on a broader scale. Many challenges lie ahead for the Global Health Service Partnership, including how to assist with the infrastructure needs of the sites and how to help to promote strategies for retention of trainees and current faculty. After the current model is piloted, the programme intends to build on its effect by increasing the number of volunteers, countries served, and health professions involved. National leaders and international authorities have pinpointed that the need for more faculty to support medical and nursing schools in resource-poor countries is a
Region or district
MD
RN
Total
Specialty
Blantyre district, Lilongwe district
5
0
5
Psychiatry, obstetrics and gynaecology (2), internal medicine, paediatrics
Malawi University of Malawi, College of Medicine Mzuzu University
Mzimba district
0
2
2
Paediatrics, comprehensive
Kamuzu College of Nursing
Blantyre district, Lilongwe district
0
4
4
Midwifery, paediatrics, comprehensive nursing and infectious disease, mental health
Gulu University
Gulu district
3
0
3
Paediatrics, internal medicine (2)
Lira School of Nursing
Lira district
0
2
2
Comprehensive nursing, public health and mental health
Mbarara University of Science and Technology
Mbarara district
3
3
6
MD: paediatrics, internal medicine, infectious disease; RN: surgical, comprehensive nursing (2)
Uganda
Tanzania Muhimbili University of Health and Allied Sciences Dar es Salaam region
2
0
2
Anaesthesiology, cardiology
MVUMI Clinical Officers Training Center
Dodoma region
1
0
1
Family medicine
Mirembe School of Nursing
Dodoma region
0
2
2
Midwifery, comprehensive nursing
Bugando Medical Center
Mwanza region
2
2
4
MD: obstetrics and gynaecology, paediatrics and internal medicine; RN: women’s health, comprehensive nursing
MD=doctor of medicine. RN=registered nurse.
Table: Number and types of volunteers sent to each site arranged by location and country
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Viewpoint
major bottleneck to the strengthening of health systems. The Global Health Service Partnership focuses on medical and nursing education as crucial to help to build sustainable health systems. We hope that the work produced through the partnership will help to highlight the need for health leadership and faculty, and show that educational investments have long-lasting benefits for students, faculty, and health systems. Contributors VBK did the literature search, data collection, data analysis and interpretation, constructed the figures and tables, and contributed to the preparation of the Viewpoint. FM contributed to the preparation of the Viewpoint. Conflicts of interest VBK is the Chief Executive Officer of Seed Global Health (formerly Global Health Service Corps). FM is the Founding Chairman of the Board of Trustees for Seed Global Health, and the Murdock Head Professor of Medicine and Health Policy at George Washington University. Funding for the Global Health Service Partnership was provided by President’s Emergency Plan for AIDS Relief, the Engelhard Foundation, Draper Richards Kaplan Foundation, Pfizer Foundation, and Goldman Sachs Gives. Acknowledgments We thank Jennifer Goldsmith (Seed Global Health, Boston, MA, USA) for her assistance in finalising the figure, table, and appendix. References 1 WHO. The world health report 2006: working together for health. Geneva: World Health Organization, 2006. http://www.who.int/ whr/2006/en/ (accessed Jan 19, 2013). 2 PEPFAR. Health Systems Strengthening. Washington, DC: Presidents Emergency Programme for AIDS Relief, 2013. http:// www.pepfar.gov/about/138338.htm (accessed Jan 24, 2013). 3 Ethiopia: Surge of doctors to strengthen health system. http:// nazret.com/blog/index.php/2012/08/16/ethiopia-surge-of-doctorsto-strengthen-health-system (accessed April 1, 2013). 4 Malawi Health Equity Network. 2010/2011 Health Sector Budget Analysis. http://www.africawindmill.org/Health-BudgetAnalysis_2010_v4.pdf (accessed April 1, 2013). 5 PEPFAR. The Universidade Eduardo Mondlane, UCSD Medical Education Partnership. http://www.pepfar.gov/partnerships/ initiatives/mepi/network/mozambique/index.htm (accessed April 1, 2013). 6 Achiek M, Lado D. Mapping the specialist medical workforce for Southern Sudan: devising ways for capacity building. South Sudan Medical Journal 2010; 3. http://www. southsudanmedicaljournal.com/assets/files/Journals/vol_3_ iss_2_may_10/ssudanworkforce.pdf (accessed Jan 21, 2013).
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