Pfeiffer, James PhD; Beschta, Julie MPH; Hohl, Sarah MPH; Gloyd, Stephen MD; Hagopian, Amy PhD; Wasserheit, Judith MD
Interest in global health has exploded at universities and medical schools across the United States over the past decade. New global health initiatives and increased support from donors such as the Bill & Melinda Gates Foundation have galvanized attention to global health and inspired students.1–8 Development assistance for health nearly quadrupled between 1990 and 2007 from $5.59 billion to $21.79 billion in contributions made through public and private channels.9 The dramatic growth in academic global health programs that has paralleled these investments motivated the establishment in 2008 of the Consortium of Universities for Global Health (CUGH), which now includes more than 100 institutions.
During this period, the University of Washington (UW), a CUGH member, identified global health as one of its four “pillars” or priority areas. In 2007, with support from the Gates Foundation and Washington State, UW established a new Department of Global Health (DGH) based in the School of Medicine and in the School of Public Health. Although the DGH is based in these two schools, its mandate has been to harness the expertise and interdisciplinary educational and research potential of all 16 schools and colleges at the university. A primary goal of this effort would be to develop a curriculum continuum from undergraduate through postdoctoral training. On inception of the DGH, the question of how to best train future global health professionals assumed new urgency.
Until recently, there has been little systematic effort to assess training needs for the burgeoning field of global health, and substantial differences in training priorities and vision exist among programs.10–13 In an early attempt to define global health competencies for UW’s master of public health (MPH) program, Hagopian and colleagues14 argued for a competency-based curriculum better tailored to real-world priorities, such as working effectively across sectors (e.g., health and transportation) and geographies through which infectious diseases now travel with increasing ease. Then, in 2009, recognizing the importance of global health training, the Association of Schools of Public Health initiated a process to identify global health competencies for master’s-level global health programs.15 Still, although many in the field of global health embrace the concept of a highly interdisciplinary, competency-based curriculum, the global health community has reached no clear consensus on what specific skills and knowledge constitute the core competencies of the field.16
In 2008, recognizing the rapidly evolving global health terrain, UW’s DGH leaders prioritized the creation of a new, competency-based curriculum, defining competencies as a combination of the knowledge and skills required to conduct specific activities. Therefore, we—the team charged with helping to develop this innovative DGH curriculum—sought to elicit opinions and perspectives from leading global health experts in an effort, first, to identify competencies and approaches to training that would be critical for contemporary global health professionals and, then, to establish a foundation for a curriculum that would train these professionals to advance global health as effectively as possible.
We elected to interview global health practitioners and leaders about the competencies and approaches they felt were most important based on their vision of the key roles that would be essential to advance global health well into the future. Although debates will likely continue concerning how “global health” should be defined, we felt that adopting a working definition for our project would be necessary to provide a framework for defining competencies and to guide the interviews. We drew a useful definition from a recent, widely cited consideration of global health16:
Global health is an area for study, research, and practice that 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 clinical care.
To generate a sample of interviewees who would, collectively, capture the institutional variation in the global health field, we compiled a list of major global health employers in three categories: “donor” (foundations and multilateral [representing multiple governments] and bilateral [representing a single government] agencies); “academic” (educational and research institutions); and “implementer” (nongovernmental organizations [NGOs] and national governmental agencies, including ministries of health). Rather than distribute a survey that might produce only cursory responses, we sought to conduct in-depth, qualitative, open-ended interviews with a limited number of global health leaders to elicit more thoughtful, frank, and reflective insights and recommendations. We chose to interview key external stakeholders among the three categories who have maintained strong connections to UW’s DGH, not only because they would be likely to provide candid recommendations but also because, as potential eventual employers of our graduates, their participation would allow us to better understand the real-world competencies required for employment in their respective organizations. The UW institutional review board granted exempt status to the project.
In summer 2008, we identified 63 leaders from these agencies, most of whom were agency directors, chief executive officers, or deans. We invited 56 potential study participants from these agencies, 46 of whom were current or former colleagues of UW faculty. We contacted each invitee twice by e-mail and, when necessary, by an additional phone call. We did not offer incentives for participating, and participation was independent of other interactions with UW.
From August 2008 to May 2009, we interviewed leaders from across the three major sectors (donor, academic, implementer). We conducted the majority of interviews by telephone in teams of two. In some cases, interviews were conducted in person and/or by a single member of the interview team. Most of the interviews lasted between 30 and 60 minutes. We audio-recorded 21 of the interviews and took notes on 5 of them.
Using a standardized, semistructured interview guide that outlined primary questions and follow-up probes, we asked each interviewee to describe the most important roles for global health professionals 20 or more years from now and to identify the key competencies required to execute these roles. We then asked them to identify, keeping those competencies in mind, what areas of knowledge and skill the new curriculum should emphasize, how educators should train global health practitioners, and who should be recruited for global health programs.
We analyzed the interview transcriptions and notes using Atlas.ti software (Berlin, Germany) to identify key themes.17 We met to develop a codebook, to discuss themes broadly shared across the sample of leaders, to increase interrater agreement on theme identification, and to select exemplar quotes that would best illustrate these key shared themes.
Of the 56 leaders we invited to participate, 26 (46%) were available and amenable. The interviewees included 7 women, 6 individuals from low- or middle-income countries (LMICs), 15 physicians, and leaders from all three major sectors (Table 1). Two participants represented more than one organization (see Table 1).
A range of key themes emerged in response to each of the three major question categories about how the DGH and other global health programs should move forward: What competencies should global health programs emphasize, how should global health programs train, and whom should global health programs train?
What competencies should global health programs emphasize?
Throughout our discussions, participants highlighted essential areas of knowledge and related skills, which together constitute competencies that they considered important for training effective global health professionals. We describe these key areas below and provide exemplary quotes to illustrate typical comments.
One of the key areas of knowledge that interviewees identified as important for global health in the 21st century is the upstream socioeconomic and environmental determinants of health. They also emphasized the importance of understanding how systems function.
Upstream socioeconomic and environmental determinants of health.
All participants believed that trainees should learn about the underlying causes of illness and health inequity (e.g., socioeconomic status, education). Notably, one interviewee remarked that the “biggest suggestion” he would make is that we train people in the social determinants of health (emphasis ours). Interviewees urged shifting the balance of training from merely cleaning up after inequities to understanding and addressing the social conditions that produce them. One interviewee stated:
Train people in the social determinants of health. These are such integral parts of global health that the students trained in this area have to see them as not just nice things to think about, but as core things to think about.
An interviewee from a donor organization indicated that his or her organization had begun to broaden its perspective from “the [traditional] global public health frame on solving problems” to a wider perspective including such issues as women’s education. Another stated: “The focus on the disease model no longer works. The curricula should be more holistic and multidisciplinary to address the root of disease.”
Finally, acknowledging the current “crisis around the environment,” many suggested that global health professionals should be enlisted to confront environmental determinants as well: “We’re talking a lot about the environment, but we’re not doing enough.”
Interviewees noted the importance of understanding systems, that is of being able to think about health in an integrated, systemic way—both within and beyond the health sector. Mere recognition of how upstream determinants affect health is insufficient unless students also learn how to address them. Doing so requires knowledge of how local and international policy and service delivery systems in key sectors function and interact. One interviewee stated:
We’re talking about people having an understanding of the health sector, which means health policy, and how health systems function, various aspects about policy, including workforce. Courses aren’t often given that orient people to the complex world and politics of international organizations.
Because health care and political systems are especially fragile in developing countries, global health training must underscore the importance of systems thinking to effective interventions. For example, many of our partners discussed the inefficiencies, policies, and poor communication that produce low-performing health systems, and they pointed to the critical roles of health system capacity building and program scale-up in the coming years. Participants emphasized that recognizing how health systems function internally, as well as how they should interconnect with other sector-wide systems (e.g., education, transportation, agriculture), is also vital to the development of effective health programs and interventions. One interviewee ventured,
[Universities need] a curriculum that also involves people who do not have [primary] expertise in health … a curriculum which makes people better able to think about how you change systems rather than just diseases, and allows them to understand much more about the system in which we’re operating.
In addition to these two broad areas of knowledge, interviewees highlighted several related skill sets which they felt were both essential to global health training and informed by the areas of knowledge discussed above.
Participants underlined the importance of training in epidemiology and in monitoring and evaluation (M&E). Described by one interviewee as the “scientific base” of global health, an understanding of the science and tools of epidemiology was deemed critical by most interviewees. Training in epidemiology and data management for global heath requires a strong foundation in the socioeconomic and environmental determinants of health and in the systems that produce, manage, and share data. With this background, one might more readily both identify appropriate metrics and interpret the resulting information properly.
In addition, interviewees stressed the importance of M&E skills both in the development of evidence-based programs and as a crucial area for health system strengthening. The value of these skills stands out in high relief in underresourced settings where many ministries struggle to improve the quality of health information system data and to better analyze those data in order to improve service delivery.
As highlighted in a recent Lancet Commission report,18 today’s ready access to an abundance of information transforms the traditional role of educational programs from primarily vehicles for transmitting information to means for helping students synthesize and apply this information in a meaningful way. Many noted that professionals who can analyze and synthesize large volumes of information for presentations and decision making will be in great demand.
Management and leadership skills.
Citing the need for the global health workforce to move effectively and efficiently within complex national and global systems, interviewees urged greater preparation in management and leadership.
Described by one participant as the “practical base” for global health, core management skills, such as planning and human resource and financial management, were seen by many as essential to implement and scale up sustainable programs within the cluttered landscape of global health stakeholders and trends. “The new global health is more management-oriented,” stressed one interviewee. Many participants stated that—like management generally—financial management skills represent a pressing need that will only continue to grow. Professionals in the field need to mobilize funds, construct and maintain budgets, and align budgets with country, organizational, and health needs as well as with donor requirements.
Leadership was another major focus of the interviews. One participant noted that “you can’t do anything alone,” and many others remarked on the importance of teamwork, collaboration, and coalition building across organizations and sectors. One interviewee, describing the current global health landscape as one in which “everyone is still in their little boxes,” emphasized the importance of producing leaders with a strategic vision to advance organizations, programs, and people with greater humility and wisdom. Others stated that future professionals must master the ability to work effectively across a number of different cultures and organizational contexts.
Policy analysis and development skills.
Most interviewees stressed that global health graduates should be able to translate research into policy and programs, and they highlighted the importance of developing policy-related skills such as stakeholder mapping, policy analysis, and advocacy, so as to catalyze change in health structures and related systems. Many participants indicated that few graduates are equipped with the “political savvy” to work in what they acknowledged is a highly political field.
How should global health programs train?
To build capacity in these knowledge and skill domains, participants emphasized that the best training would include hands-on, real-world experiences in processing and presenting information, collaborating with partners, and implementing programs. Although this hands-on training is important to all health subdisciplines, it has heightened value for global health professionals, given the rapidly changing and variegated work environments that graduates will encounter.
Case studies and experiential learning.
Interviewees encouraged the honing of trainees’ skills by emphasizing, in addition to critical thinking, actual doing—either experientially, as in collaborations with outside organizations, or through case studies and problem-based course work that mimics real-world content. One participant stated that universities are currently
preparing people in a theoretical program for jobs that actually require practical skills that they’re not given any preparation for. It is designed by academics not recognizing the professional reality on the ground.
Another interviewee noted that universities produce an abundance of “education-rich and experience-poor” graduates. Still another said:
It’s always bothered me that if you want to become a pediatrician, you have to take care of sick children. You can’t simply go to class. And yet in schools of public health, we allow people to just go to class, and you don’t ever have to take responsibility for a community…. We [must] learn how to get faculty and students responsible for things in the community; that’s the way to do hands-on training.
Interdisciplinary and interprofessional collaboration.
Regardless of each trainee’s career trajectory in global health—clinical work, health systems management, or shaping determinants through policy and politics—all trainees, according to most of our interviewees, must have the ability to work effectively in teams and build coalitions across sectors and organizations. One participant said,
I hope that the lessons learned in the last 10 years about cooperation will grow, and that more cooperation will exist, not just within those in the health community and those concerned with global health, but across disciplines; and that they would work more closely with each other rather than [be] oppositional by default.
To this end, interviewees urged UW and other universities to develop meaningful collaborations within and among their institutions as a means of better preparing students to work across sectors and professions. Even though the value of interdisciplinary training in global health is widely noted,14,18–20 participants consistently commented on its absence. One participant stated:
Where is the understanding of the sociology, the anthropology, the economics, and the policy issues that are needed for global health? They don’t exist in medical school, and they don’t exist in schools of public health. Period. I rest my case. So we, you and I, we’ve missed it.
Another stressed: “It is going to take more than infectious disease people to address this problem. It is going to take just about every discipline known in health and in arts and sciences to go after this.”
Whom should global health programs train?
Interviewees stressed that the complexity of the new global health context will require an expanded notion of the “global health workforce” and a reach beyond those whose primary training is in the health sciences. For example, one participant stated:
The bottom line is, because of this complexity, who is needed for global health is a new generation that has multi-talents, that is not coming from one brand of training, that is not coming from a biomedical background or a public health background or an “X” background. To train the global health leaders of the future we need [professionals with] a complex set of abilities who understand economics and the political scene and the culture and the social, as well as the scientific.
Developing global health competence among non-health-sector groups, to build what one referred to as “frontier employment structures,” clearly has implications both for whom to recruit and the kinds of professionals to produce as graduates. Participants underscored the importance of striking the optimal balance between health and nonhealth trainees, between generalists and specialists, and between students from LMICs and those from high-income countries.
Drawing both on this rich fabric of competency and training recommendations derived from the interviews and on the landmark 2010 Lancet report mentioned above,18 the leaders of UW’s DGH are currently revising the DGH curriculum across programs. The authors of the Lancet report, “Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world,” systematically reviewed the current state of health professional education (focusing on medicine, nursing, and public health) and outlined key areas for instructional and institutional reform. The authors highlighted the need for a paradigm shift in health professional education that better responds to the new challenges and advances in health and higher education over the past century. Their findings complement the recommendations of our interviewees, and we are mapping the DGH curriculum to include the following essential interrelated competencies: (1) knowledge of the social, economic, and environmental determinants of health, (2) knowledge of the architecture and levers of health, health-relevant systems, and health service delivery, (3) skills in epidemiology and in M&E, (4) capacity for management and leadership, and (5) skills in policy analysis and development. The objective is to design a curriculum that not only provides basic fluency in these key areas for everyone (from undergraduate through postdoctoral trainees) in any DGH program but also offers opportunities for specialized higher-level training to graduate and postgraduate students. The new curriculum will seek to train for these competencies, using the following approaches recommended by interviewees.
Interdisciplinary training and interprofessional collaboration
The DGH is building interdisciplinary collaboration through a series of initiatives and relationships. A university-wide Global Health Curriculum Advisory Committee, created at the inception of the DGH with members appointed by the dean of each UW school and college, has been instrumental in program development. Since the beginning of the DGH, the committee has helped guide curriculum development, and, more recently, it has leveraged campus-wide curricular initiatives (e.g., new graduate certificates in global injury and violence prevention and control, and in global health of women, adolescents, and children). In addition to these new interdisciplinary graduate certificates, the DGH recently launched an undergraduate minor in global health. All of these involve faculty and students from across campus including from the social sciences, law, engineering, climate change and the environmental sciences, business, architecture, and urban planning. These minor and certificate programs encourage students to receive a basic credential in global health to complement their major degree. Further, the DGH has also started a global health leadership training course for UW medical residents. By drawing students from diverse disciplines into global health courses, these new programs enrich the learning environment for all students. Concurrent degree programs, interdisciplinary research, and a weekly, open-to-all global health seminar also bring together a broad range of disciplines from across the university. UW’s DGH also brings together people from across the globe; UW is one of four U.S. universities collaborating with four African universities in the Afya Bora (“Better Health” in Swahili) Global Health Leadership Training Fellowship Program.
In addition to core degree requirements, the curriculum of the MPH in global health offered by the DGH has been strengthened so that all students will receive some level of training in leadership, policy, and management skills. Content on finance, planning, and human resources has also been strengthened in existing course work. These analytic, management, leadership, and policy skills come together in “implementation science”—a rapidly emerging field that provides an interdisciplinary framework for applying rigorous methods to increase the speed, fidelity, and effectiveness with which interventions of documented efficacy are translated into real-world programs and scaled up to district, national, regional, or global levels. Implementation science defines a key set of competencies that marries knowledge of health determinants and delivery systems to skills in areas such as surveillance, impact evaluation, economic analysis, operations research, quality improvement, stakeholder and policy analysis, dissemination research, and social marketing. Recognizing the critical importance of this growing field, which seeks to bridge the “know–do” gap,21 for global health professionals, the DGH, in 2010, started a graduate course in implementation science and, in 2012, initiated a PhD program in global health metrics and implementation science.
The DGH has built upon relationships with local and international partners to broaden and deepen our training through experiential learning. The Afya Bora Global Health Leadership Training Fellowship Program (mentioned above) includes rotations with NGOs, governmental agencies, and academic institutions in Africa so that program participants are able to implement research or programmatic projects (e.g., the implementation of cervical cancer screening in a poor resource center in Kenya; the evaluation of a patient retention intervention in HIV/AIDS care and treatment centers in Tanzania; the development of evidence-based recommendations to guide the implementation of the 2011 Botswana TB/HIV policy guidelines). Our MPH program encourages both a field-based thesis with close faculty mentorship and a practicum experience with a global health organization. Several of the DGH centers, including the International Training and Education Center for Health and Health Alliance International, provide technical assistance or are involved in collaborative service delivery projects and offer opportunities for students to conduct thesis research and gain practical experience working with NGOs or ministries of health. Through both the interdisciplinary initiatives and the experiential learning efforts, the DGH programs actively recruit students and trainees from LMICs and across disciplines. These students have formed a rich and diverse mixture of new global health professionals who receive a common foundation in their training while still retaining the knowledge and skills of their own disciplinary specialties.
The global health community has a unique opportunity to redefine and strengthen the way it prepares the next generation of global health professionals. To seize this unprecedented opportunity, we believe that the roles that 21st-century global health professionals should play must evolve as fast as the field. Our vision is of a truly interdisciplinary and interprofessional, competency-based curriculum that is delivered in innovative, interactive ways. We must commit the resources to monitor and evaluate the impact of these new curricular models and to iteratively improve them. Evidence-based education and training that is designed with the end in mind will prepare our future leaders to transform global health.
Acknowledgments: The authors wish to thank the following for their participation: Donna Barry, Lincoln Chen, Humberto Cossa, Ann Downer, Mark Dybul, Christopher Elias, William Foege, Julio Frenk, Helene Gayle, Adrienne Germain, Peter Hotez, Anne Johnson, Jeffrey Koplan, Andrew Levack, Adel Mahmoud, El Tayeb Mansour, Susan Masse, Stephanie McAuliffe, Michael Merson, Fitzhugh Mullan, Antonio Mussa, Peter Piot, Thomas Quinn, Ramon San Pascual, Kenneth Stuart, and James Williams.
Other disclosures: None.
Ethical approval: The University of Washington institutional review board approved the study protocol for this report.
Previous presentations: Some of the data in this report have been presented at the Consortium of Universities of Global Health meeting, September 2010, University of Washington, Seattle, Washington (Sarah Hohl); at the American Public Health Association Conference, November 2010, Denver, Colorado (Sarah Hohl); at Futures in Global Health Career Day, March, 2011, University of Washington, Seattle, Washington (Sarah Hohl); at the Association of Schools of Public Health Webinar, May 2009, University of Washington, Seattle, Washington (Steve Gloyd); and at the Global Health Education Consortium Conference, April 2009, University of Washington, Seattle, Washington (Steve Gloyd).
2. Fryatt R, Mills A, Nordstrom A. Financing of health systems to achieve the health millennium development goals in low-income countries. Lancet. 2010;375:419–426
3. Pfeiffer J, Johnson W, Fort M, et al. Strengthening health systems in poor countries: A code of conduct for nongovernmental organizations. Am J Public Health. 2008;98:2134–2140
4. Gilson L, Sen PD, Mohammed S, Mujinja P. The potential of health sector non-governmental organizations: Policy options. Health Policy Plan. 1994;9:14–24
5. Samb B, Evans T, Dybul M, et al.World Health Organization Maximizing Positive Synergies Collaborative Group. An assessment of interactions between global health initiatives and country health systems. Lancet. 2009;373:2137–2169
6. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. Global health in medical education: A call for more training and opportunities. Acad Med. 2007;82:226–230
7. Haq C, Baumann L, Olsen CW, et al. Creating a center for global health at the University of Wisconsin–Madison. Acad Med. 2008;83:148–153
9. Institute for Health Metrics and Evaluation.Financing Global Health 2010: Development Assistance and Country Spending in Economic Uncertainty. 2010 Seattle, Wash Institute for Health Metrics and Evaluation
10. Potter MA, Pistella CL, Fertman CI, Dato VM. Needs assessment and a model agenda for training the public health workforce. Am J Public Health. 2000;90:1294–1296
11. Macfarlane SB, Jacobs M, Kaaya EE. In the name of global health: Trends in academic institutions. J Public Health Policy. 2008;29:383–401
12. Houpt ER, Pearson RD, Hall TL. Three domains of competency in global health education: Recommendations for all medical students. Acad Med. 2007;82:222–225
13. Battat R, Seidman G, Chadi N, et al. Global health competencies and approaches in medical education: A literature review. BMC Med Educ. 2010;10:94
14. Hagopian A, Spigner C, Gorstein JL, et al. Developing competencies for a graduate school curriculum in international health. Public Health Rep. 2008;123:408–414
15. Calhoun JG, Spencer HC, Buekens P. Competencies for global heath graduate education. Infect Dis Clin North Am. 2011;25:575–592, viii
16. Koplan JP, Bond TC, Merson MH, et al.Consortium of Universities for Global Health Executive Board. Towards a common definition of global health. Lancet. 2009;373:1993–1995
17. Russell HR, Ryan GW Analyzing Qualitative Data: Systematic Approaches.. 2010 Thousand Oaks, Calif Sage Publications
18. 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;376:1923–1958
19. Pfeiffer J, Nichter MCritical Anthropology of Global Health Special Interest Group.. What can critical medical anthropology contribute to global health? A health systems perspective. Med Anthropol Q. 2008;22:410–415
20. Beaglehole R, Sanders D, Dal Poz M. The public health workforce in sub-Saharan Africa: Challenges and opportunities. Ethn Dis. 2003;13(2 suppl 2):S24–S30
21. Madon T, Hofman KJ, Kupfer L, Glass RI. Public health. Implementation science. Science. 2007;318:1728–1729