Ackerly, D. Clay MD, MSc; Udayakumar, Krishna MD, MBA; Taber, Robert PhD; Merson, Michael H. MD; Dzau, Victor J. MD
The evolving impact of globalization on health and health care, which includes such trends as threats of worldwide pandemics, unsustainable increases in clinical care and research costs, continued global economic uncertainty, “medical tourism,” and local and global health disparities, has challenged the status quo for many U.S. health care industries. Spurred by these challenges, as well as by attendant opportunities, academic medicine is beginning to engage in globalization. Although some of these activities have prompted skepticism or criticism, we believe that investing in global medicine is critical to the long-term success of the U.S. academic medical enterprise.
Academic Health Science Systems and Leadership in Global Medicine
The term academic health science system (AHSS) describes the modern academic medical enterprise, which combines the resources of medical and health professions schools with advanced research infrastructures and integrated health care delivery systems.1 AHSSs are unique in encompassing education, research, and clinical care missions and, therefore, can access an expanding plethora of opportunities across these missions to engage in globalization.
Although we recognize that some AHSSs may choose to focus on local or national missions, we believe that AHSSs in general should engage in global medicine, motivated not only by a sense of global responsibility but also by enlightened self-interest.2–4
It no longer suffices for AHSSs to provide care only to those patients who come through their doors. Deficiencies in environment, hygiene, economic development, and access to health care are at the root of dramatic disease burdens and shortened life expectancy for five billion of the world's six billion citizens.5 AHSSs must invest in, and accept responsibility for, the health of their communities by addressing population health locally, nationally, and globally. AHSSs have the opportunity to address global health disparities, whether through direct service provision, conducting research relevant to the needs of the resource-constrained, or contributing to the supply of global human capital.
However, expanding the institutional scope of activities to include international activities need not be motivated by altruistic goals alone, and the boundaries between charity and maintaining competitiveness are blurring. Global medicine can serve to amplify the impact of academic research, education, and clinical care missions as well as prepare AHSSs for the challenges of a rapidly changing world.
Further, given that globalization is opening up the health care systems of developed economies to new sources of competition (e.g., medical tourism and telemedicine), going global is not simply an option but a strategic imperative for many AHSSs. Across all activities, action carries risk, but so does inaction. For example, collaborations among emerging and developing economies are happening with or without engagement from developed nations (e.g., Brazil's efforts in Africa to establish schools of public health and to improve HIV-AIDS prevention and pharmaceutical manufacturing).6 These efforts are to be applauded, but they also warn us that established institutions could be left behind if they do not participate globally as future paradigms are created.
In short, we believe that despite the risks of globalization, which we discuss at length below, AHSSs have the capacity to assume a leading role in global medicine as well as the moral and business imperatives to do so.
The Opportunities for AHSSs in Global Medicine
Despite the potential risks, several AHSSs have recognized the potential offered by global medicine and have begun to expand their international activities. These investments span their academic missions, combining research, care delivery, and education. The largest global medicine programs admittedly have been focused on partnerships with wealthy nations (a few prominent U.S. and European examples are listed in Table 1). However, activities have not been limited to medical schools. Other experiments are under way in allied professions (such as nursing,7 dentistry,8 and public health9) and through the creation of interdisciplinary institutes or centers.10
Many AHSSs have had faculty and programs engaged in research internationally for many years, and these activities continue to expand organically. However, these international activities must become more strategic. Given the constraints affecting U.S. research funding and the ongoing expansion in international research infrastructure and investment (such as that demonstrated by the growth of science parks and biotechnology industries in many countries, including China,11,12 India,13 and Singapore14), AHSSs must develop strategic international partnerships to accelerate the translation and commercialization of their basic biomedical discoveries.
This emerging global infrastructure is also creating new competitors in research for AHSSs. Research funding is relatively finite, and as research dollars increasingly flow overseas (in part because of the lower costs of conducting research abroad), support at home is at risk.15 In basic science, outsourcing is common. One example is the high-throughput screening conducted at relatively low cost by companies such as BGI (formerly known as the Beijing Genome Institute).16 Although such work may be considered “commoditized,” as the infrastructure grows, it can—and likely will—support more “innovative” (and directly competitive) efforts. Clinical research is also experiencing tremendous international growth due to lower costs, faster patient enrollment, and fewer regulatory hurdles abroad.17 Emerging economies are in the vanguard of this growth,18,19 presenting both challenges and opportunities regarding workforce development and strengthening of human subjects research protections.
In addition, governmental support is a significant driver of expanded capacity. For example, as early as 2001, public research and development spending in low- to middle-income countries had been estimated at more than $2 billion annually, and it has continued to expand.6 In Singapore alone, more than $20 billion has been invested by its government to cultivate research and development capacity and associated industries.20 This international growth in capacity presents opportunities for collaboration and for increasing the productivity of laboratories both at home and abroad, thus supporting not only improvements in human health but also economic development.
Through more traditional collaborations (e.g., participation in international research networks) and newer outsourcing efforts (e.g., sending portions of projects overseas to lower overall costs and to improve grant competitiveness), AHSSs have begun to take advantage of globalization in the area of research. However, efforts are expanding beyond traditional collaborations and can include significant on-the-ground investments. For example, in February 2011, Duke Medicine announced the Medanta Duke Research Institute, which is building a 60-bed early-phase clinical research facility in India to conduct high-quality, proof-of-concept human studies.21 In addition, Duke is affiliated with a similar unit in Singapore through its Duke-National University of Singapore (NUS) Graduate Medical School. This international network of state-of-the-art clinical research units will produce a coordinated, innovative effort investigating human systems biology and novel approaches to drug development.
Care delivery presents numerous opportunities for AHSSs, including consulting and cobranding arrangements, comprehensive management contracts, co-ownership of international care delivery enterprises, and more. Many AHSSs have developed expertise in integrated delivery systems, evidence-based medicine, and state-of-the-art technologies that can be adapted to serve diverse communities.
Direct service provision in underserved areas affords the opportunity both to accommodate unmet health care needs today and to help support the development of a health care infrastructure that will meet patients' needs over the long term. That said, many of the efforts have not focused on underserved markets and have responded to pressures affecting the clinical enterprises of AHSSs at home. Historically, AHSSs have been resources for specialty care and training worldwide, with many international patients traveling to them to receive care. This has changed since the events of September 11, 2001, with international patients seeking alternatives.22 When pressures from reduced reimbursement by U.S. payers and competition from other providers at home and abroad are considered, it is unsurprising that some AHSSs have turned to international activities to attract patients or develop other revenue opportunities.23
Importantly, the rise of “medical tourism” (patients actively seeking care abroad, whether for cost or quality reasons) has led to increased competition from foreign hospitals. Estimates of market size vary; one conservative estimate puts the potential annual volume of U.S. patients who could travel abroad to seek medical care at 500,000–700,000 persons, representing $35 billion in clinical revenue.22 Other estimates suggest that the size of the global medical tourism market is $60 billion or more.24,25 Regardless of the exact number, the heightened competition is real, and the arrival and expansion of various international accrediting bodies signal that global health care standards are emerging and the playing field is leveling. One such organization, the Joint Commission International, has grown substantially since its founding in 1997. In 2000, it had accredited just three institutions; by 2010, it had accredited more than 300 institutions in 39 countries.26 Other bodies, such as the International Society for Quality in Health Care and the United Kingdom's Trent Accreditation Scheme, are also accrediting international provider groups.24
Further, the effects of global competition are felt even if few patients travel abroad. For example, in 2008, one large employer in New England leveraged an agreement with a Singaporean hospital in order to negotiate lower prices from U.S. providers.27
By globalizing clinical care activities across various service lines (whether through consulting, management, or on-the-ground service provision), AHSSs can monetize their expertise in health care delivery without expanding locally. Although success is not guaranteed, such projects are diverse in nature and will likely continue for the foreseeable future.
Finally, global medicine offers “bidirectional” learning in clinical care delivery—fostering mutual exchanges of experiences, care models, and even technologies—in which developing economies provide platforms to develop creative solutions that can be applied in developed economies, as well as the reverse.28 For example, low-cost, high-throughput specialty care models are being established in low-resource environments in India, including the Aravind Eye Care System29 and LifeSpring hospitals, the latter of which provides high-quality, affordable maternity care to poor women.30 These programs often incorporate novel approaches to high-volume, high-throughput, routinized technical care, creative use of human capital (e.g., community health workers), and effective patient outreach programs that may be applicable to community-based care delivery in the United States and other developed countries.
In addition to these important global research and clinical care activities, education and workforce development also present significant near-term opportunities for the growth of AHSSs, as well as offering great potential for achieving lasting improvements in health globally. The existing global health care workforce is inadequate—The World Health Organization (WHO) estimates that an additional four million workers are required to satisfy current global needs.31 Addressing this problem, however, requires immense effort: For example, the WHO also estimates a cost of $2.6 billion per year for 10 years to train an additional 1.5 million workers just to meet the health care workforce needs of African countries.32
Although the scope of this problem is clearly beyond the capacity of AHSSs alone, they can still play an important role in both developing and developed nations, and innovative, scalable models of education are needed to reach greater numbers of learners. Furthermore, the present health care workforce shortage is exacerbated in less developed nations by the lure of higher salaries and better working conditions in more developed nations33—a circumstance that requires engagement by parties on both sides of the equation. In addition, human capital development should not only expand the workforce but also seek to improve the quality of workers across the spectrum of training (e.g., preprofessional, graduate medical, nursing, research, allied health). This requires new paradigms that incorporate novel methods of knowledge acquisition, problem solving, teamwork, and multidisciplinary care.
The opportunities for AHSSs are vast and include three major categories across all types of learners (e.g., physicians, nurses, allied health professionals, managers): (1) exchange programs (typically where learners and/or educators travel), (2) distance learning education activities (where learners and teachers largely remain in the same place and engage in Web-based and other “over-the-air” activities), and (3) development of full-fledged schools overseas. To date, few AHSSs have undertaken significant international activities beyond focused exchange programs, although examples of increased international commitments are appearing.
Exchange programs have long existed to help meet the needs of underserved communities, but these generally have been insufficient and fragmented. One example of an effort aimed at addressing this problem is the Medical Education Partnership Initiative, whose aim is to both train and retain approximately 140,000 health care workers in Africa.34 Supported by a $130 million grant from the U.S. government, it is creating a network of academic and governmental institutions (over 30 collaborators in Africa and 20 in the United States, many of which are AHSSs). On a smaller scale, another workforce innovation taking place at AHSSs is the development of global health residency programs.35,36 These typically incorporate targeted didactics and applied international health experiences to develop a cadre of global health leaders amongst U.S.-trained physicians.
AHSSs have developed various innovative Web-based and virtual teaching methods,37 including “tele-education” services. Such technology can help translate expertise in culturally sensitive ways, strengthening and expanding the number of global health care workers while also leveraging existing international partnerships to reach new learners. For example, Duke Medicine has partnered with Kaplan EduNeering to provide virtual (and global) workforce training in the area of clinical trial management as a way to improve the infrastructure and quality of international clinical trials.38 U.S. AHSSs are not alone, however: To date, Indian universities have made an investment in setting up distance learning centers in Africa, as well.39,40
In addition to these more focused areas, AHSSs have also made investments in establishing entire schools abroad, with large potential risks and rewards. For example, Columbia University has helped operate a medical school in Israel for some time,41 and Johns Hopkins University recently announced its plan to build the first “Western-style” medical school in Malaysia.42 Also, the Weill Cornell and Qatar Foundation collaboration is one of the first such schools, and their experience is instructive. The sister campus of Cornell's New York-based medical school in Qatar grants full Cornell degrees to Qatar campus graduates.43 However, those degrees do not yet hold equal value because the Qatar campus is not recognized by U.S. accrediting bodies (e.g., the Liaison Committee on Medical Education), and its graduates, unlike their New York counterparts, must apply to U.S. residency programs as international medical graduates.
More than five years ago, our institution, Duke University, entered this arena with the establishment of a medical school in Singapore. Cornell's experience, as well as those of others, helped inform the partnership between Duke and the Singaporean government in the creation of the Duke-NUS Graduate Medical School. In 2000, Singapore launched its Biomedical Sciences Initiative, a multi-billion-dollar program to support the development of a knowledge-based economy; however, the necessary physician-scientists and clinical researchers were lacking. Through a commitment of several hundred million dollars, Duke and NUS founded a new graduate medical school to enhance Singapore's emerging biomedical sciences infrastructure.44 Being mindful of earlier examples, the Duke-NUS partnership established specific goals, metrics, and timelines early in the process; these measures continue to play a central role in this collaboration.45 Through this focused approach, all key performance indicators for the Duke-NUS Graduate Medical School were met well ahead of schedule, and the initiative is considered to be a success. Indeed, Duke and NUS recently announced the long-term continuation of the partnership with sustaining funding from the government of Singapore.46
Potential Risks of and Early Lessons From Global Medicine
Inaction may result in missed opportunities, yet engaging in global medicine activities entails financial, organizational, politico-legal, and reputational risks for AHSSs. Further, although profit should not be the goal, global medicine must have sustainable business models.
From an organizational perspective, there are concerns about bandwidth for faculty and staff, dilution of intellectual and institutional assets, and efforts needed to establish institutional buy-in for new activities. New personnel may be required abroad, posing unique human resource challenges, such as quality control and ensuring attitudes consistent with institutional culture. Cultural differences may also lead to divergent expectations, both in process and in outcomes.
The myriad legal and political risks vary according to national legal systems, political environments, and the relationship of AHSS activities with foreign interests. Foreign business practices may be incompatible with domestic standards, and managing political relationships can require significant effort from senior executives. Further, engaging in care delivery and human subjects research, where the potential for direct harm is highest and most visible, dramatically increases political/legal risks.47
Global medicine, still in its infancy, is quickly evolving and requires flexibility and midcourse corrections. However, two early lessons for AHSSs are already manifest: staying mission focused, and engaging in durable public-private partnerships. Because partnerships with foreign entities usually include financial arrangements, misalignment between mission and business practices can occur. Staying mission focused is therefore critical to success, and periodic reevaluation by AHSSs of their global medicine activities will help ensure mission-activity alignment and, when necessary, can highlight the need for changes in organizational structure. The recent movement of Harvard Medical International from the University to Partners Healthcare is an example of such realignment.48,49
The opportunities and challenges of global medicine are too large, and the solutions too complicated, to be addressed alone. Thus, partnerships should be established in a deliberate fashion. Cultural differences are best explored and overcome through personal interactions. An “on-the-ground” presence is therefore critical to establishing trust and forging the lasting relationships50 that are critical to long-term success.
Given the complexities of health care, the socio-legal and political issues in different countries, and the significant resources needed, public-private partnerships offer an appealing and successful model.51–53 When evaluating potential partners, AHSSs must consider aspects such as a record of successful relationships, cultural compatibility and understanding, and alignment of goals. Further, to optimize the potential bidirectional gains of the relationship, each partner's needs should be complemented by strengths offered by the other.
Policy Changes to Support Global Medicine
To facilitate global medicine, several critical factors should be addressed. Policies to improve international research efforts, particularly in the area of clinical research, have been well characterized elsewhere and remain important.17 Issues surrounding international clinical care collaborations are beginning to emerge as well. As the demand for cross-border care increases, so does the need for rigorous, meaningful accreditation; transparency in quality and outcomes; and effective means for supporting continuity of care. Providers both in the United States and abroad, accreditation bodies, and payers (including Medicare and its private contractors, such as Medicare Advantage plans) must engage to ensure that foreign competition is not only robust but also healthy for patients. Workforce development and education are among the most urgent needs, and intervention may be most beneficial in this arena because market forces have done little to meet current demand.
Although some U.S. accrediting organizations (such as the Joint Commission) have begun to accommodate international applicants, others, such as the Liaison Committee on Medical Education, which accredits U.S. medical schools, have not. Organizations in developed countries should approach globalization in their own ways, but we strongly believe that harmonizing best-quality standards and accepting international institutions is important to develop high standards that are shared globally, and deserves support.
Some may harbor concerns that such global accreditation could either exacerbate “brain drain” in lower-income countries or, conversely, reduce the flow of international students to educational institutions in developed countries. However, the likely result is not entirely clear. Although concerns regarding brain drain are understandable, the reverse may in fact occur because the opportunity to receive accredited education at home will allow students and educated workers to remain in their own countries. For example, the Duke-NUS Graduate Medical School permits students to get U.S.-style and quality education (with a joint Duke-NUS degree) without having to travel to the United States. The final equilibrium or “trade balance” of workers and students is presently unknowable; however, we support a “free trade” approach to workforce development, and improvements in global health outcomes will be enabled through robust training unencumbered by cross-national restrictions and supported by common quality standards. For example, common global accreditation standards would promote a more portable health care workforce that could address some of the current difficulties in working across borders, leading to a global workforce more responsive to demands and health needs.
Both targeted funding and improved standards and regulations may prove helpful. In addition, expanding programs to train clinicians—as well as other health care workers—in the economic and social factors that contribute to health disparities, as well as providing opportunities for international experiences such as those provided by global health residency programs, would be beneficial in developing future leaders in global medicine.
AHSSs are beginning to engage in global medicine activities. This is encouraging, as we believe that despite the risks of globalization, the risks of inaction are greater. AHSSs have the capacity to assume a leading role in global medicine, as well as the moral and business imperatives to do so. By leveraging their myriad strengths through strategic partnerships, AHSSs can amplify the impact of their mission-based activities while addressing health disparities both at home and abroad.
The authors wish to thank R. Sanders Williams for input on an earlier version of this manuscript and Jonathan McCall for editorial assistance.
Supported by a grant from the Duke Endowment.
The authors all work for academic health science systems and declare that they have no other conflicts of interest regarding the content of this manuscript.
This manuscript draws from concepts presented at the AAHC International Forum in 2008, and the Aspen Health Forum in 2009.
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