The low- and middle-income countries (LMIC) of the world suffer a disproportionate and overwhelming burden of disease and premature death. Most observers believe that the United Nations Millennium Development Goals, created to address this imbalance, will not be reached for most of the world's population by the target date of 20151 due to a persistent shortage of human resources in these countries. For example, Africa shoulders 24% of the world's burden of disease while having only 3% of the world's health care workforce.2 Health problems in the LMICs cannot be addressed effectively without major advances in their health sciences education programs.
While Western democracies have more recently begun to address these problems with renewed determination (e.g., the Medical Education Partnership Initiative), inadequate coordination and poor alignment with local needs have limited their potential success. For example, project leaders frequently have failed to coordinate their efforts with (and sometimes have blatantly ignored) local health ministries, leading to soured relationships with the host country and ultimately inadequate capacity building.
We propose that efforts to improve health in developing countries would be facilitated by aligning health sciences education programs with the health care needs of the country. Four principles should guide this process.
First, a vision for this effort should reflect the circumstances of the country and draw on the definition of global health created by the Executive Board of the Consortium of Universities for Global Health:
Global health … places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level care.3
Second, developing and reforming medical schools should follow the strategic directions described in the Global Consensus for Social Accountability of Medical Schools4: (1) Anticipating society's health needs, (2) Partnering with the health system and other stakeholders, (3) Adapting to the evolving roles of doctors and other health professionals, (4) Fostering outcomes-based education, (5) Creating responsive and responsible governance of the medical school, (6) Refining the scope of standards for education, research, and service delivery, (7) Supporting continuous quality improvement in education, research, and service delivery, (8) Establishing mandated mechanisms for accreditation, (9) Balancing global principles with context specificity, and (10) Defining the role of society.
Third, a participatory action research (PAR) approach should be used to determine needs, design policy and implementation, and assess results of any improvement project. PAR employs systematic inquiry of behavior and performance. Central to action inquiry technologies like PAR is a recurring cycle of planning, action, evaluation, and new actions based on the results of previous actions. These techniques combine the skills, perspectives, and interests of researchers and “subjects.” In PAR, “subjects” become full partners and share responsibility for design, implementation, and reporting.
Fourth, techniques known as appreciative inquiry (AI) should be the primary mode for gathering information. AI involves asking questions that strengthen a system's capacity to apprehend, anticipate, and heighten positive potential, accelerating imagination and innovation.
Programs that adhere to these principles could take many forms. For example, the academic health centers of developed countries could assemble consulting teams based on the specific needs of developing institutions, focusing on any phase of medical education, from prematriculation programs to continuing professional development. Consulting teams would help with every step of the PAR process, without creating binding partnerships that might confuse interests and intents. Such a consulting service might even be multi-institutional, or could be administered through a professional organization.
Global health is a global responsibility, but sustainable solutions will require local ownership. Capacity building is the watchword of many initiatives, and with this must come a commitment to the creation of healthy relationships that eschew dependencies. We believe that the principles outlined above should guide the formation of supportive relationships that harness the expertise of medical educators worldwide while respecting the primacy of the home institution and its host country.