Interest in global health initiatives among medical schools in the United States and Canada is increasing. In less than four years, the Consortium of Universities for Global Health has grown to include over 50 U.S. and Canadian institutions that offer global health programs.1 These programs are often referred to as “centers”1 because of the interdisciplinary approaches they embrace which transcend traditional academic units such as departments and schools. The impetus for these initiatives is several-fold. For research institutions, substantial funding has been available, particularly for work on diseases such as HIV, tuberculosis, and malaria in underresourced regions such as Sub-Saharan Africa (SSA).2 – 4 Another driver of the increasing number of global health initiatives pertains to the demand from U.S. medical students and residents for international experiences in the developing world.5 – 7 Often, these experiences relate to relief work, service-learning, and/or so-called humanitarian missions, although some also align with trainees' research projects. Finally, some academic health centers have explored strategies to provide health care or increase referrals to their home institutions by establishing a presence in foreign countries.8
In pursuit of their interests, many academic institutions in the United States, Canada, and Western Europe (subsequently referred to as the North*) establish partnerships with academic faculty or institutions in underresourced areas of SSA. Some of these partnerships are limited to focused investigator-to-investigator relationships, and some are more expansive, including a broader array of initiatives through institution-to-institution relationships.9 The term “twinning” has been used for initiatives that are shared projects intended to be of mutual benefit.10,11 Most often, however, partnerships are driven by institutions in the North that are able to leverage the funding that, in turn, dictates the work that is to be done.12 The results of such relationships—as well as the metrics used to evaluate these results—have typically focused on research grants, new research findings, or the exchange of learners and faculty between institutions. Few metrics have examined the effects on the institutions in underresourced areas. Concerns have been raised about the risk for these institutions to become either “annexed research sites” for researchers from high-income countries or venues managed by expatriates that often employ staff who have been lured away from the local institutions with inflated salaries.12
Herein, we present an approach to collaborations between medical schools in the United States and in SSA that explicitly focuses on achieving equal partnerships that will strengthen institutions in, and, in turn, improve health outcomes in, SSA.
The Needs of Health Science Institutions in SSA
SSA represents a diverse collection of countries whose histories, cultures, and languages have been influenced by colonial powers. The medical schools and health systems that have grown out of these histories are as diverse as their languages and cultures,13 although they do share some common challenges, notably the profound lack of skilled health care workers. SSA is home to 24% of the world's disease burden but only 3% of the world's health care workers.14 Although this discrepancy is the topic of a growing number of reports and calls to action,15 – 18 the financial support to provide the workforce necessary to transform health is relatively meager.
The situation is exacerbated by an inadequate medical education system, which, some have argued, is a legacy dating back to colonial times.19 – 22 The number of schools in SSA is relatively few—as is the number of students that they graduate.23 Further, most schools suffer from insufficient infrastructure, faculty, information technology networks, and curricula.23
Other factors affecting health in SSA that need to be addressed by local governments, especially the ministries of education and of health, include the inability to appropriately employ the physicians who do graduate, ineffective mechanisms to properly distribute health care workers,16 – 18 and brain drain.24,25 Doctors and nurses from SSA (like those from similarly underresourced places12) are often lured away to more affluent countries—or to cities and administrative or nongovernmental organization positions within their own countries.24,25
Additionally, the alignment of medical schools in SSA with the needs of governmental sectors such as the ministry of health is often suboptimal. Typically, the curriculum is not linked to the competencies needed in the workplace.18 Medical schools in SSA also face the challenge of increasing their social accountability by improving the education of their graduates so that doctors can better deal with the needs of society and respond to relevant national priorities.26
Other areas of medicine in SSA also require reform. There is a substantial need in SSA to develop systems involving a coordinated approach by teams of health care workers, but evidence regarding effective, team-based policies in SSA is lacking.27 In many areas of the world, including SSA, doctors assume leadership positions in health care systems without having received adequate training in management and leadership.28 Finally, some professional societies in SSA seek to protect their members' roles in the health system and block efforts to shift tasks to other cadres.18
Partnering for Education and System Strengthening
Medical schools in the North have partnered with medical schools in SSA for decades. Several concerns have arisen regarding the construct of some of these relationships. First, as mentioned, some of these relationships are driven by a Northern agenda that may overlook the needs of stakeholders in SSA. If not constructed appropriately, these relationships may be more successful at either breeding dependency in partner SSA institutions or promoting brain drain.29 Although admirable in intent, many of these initiatives can be rightly viewed as another form of neocolonialism.20,21 Second, these relationships run the risk of being transitory either because of dependence on time-limited funding sources (e.g., a five-year grant) or, more typically, accomplishment-oriented research (e.g., a greater understanding of a disease process or intervention); they do not typically focus on institutional strengthening through faculty development or curricular reform that requires a more long-term commitment. Third, some of these relationships include a component by which trainees or transitory workers from the North provide medical care to patients.30 Although some of these relationships may be beneficial, many are “educational” experiences with poorly defined objectives and inadequately supervised trainees. Such experiences raise ethical questions concerning the local effect on and long-term value to the host country, particularly for short-term experiences.31 – 33 For academic partnerships to be of benefit to schools in SSA, they need to be intentionally structured to provide value to both institutions. Creating such a structure requires active efforts to avoid the unequal benefits that have occurred historically.29,34,35
Some partnerships have begun to help strengthen institutions in SSA. Some examples are the numerous partnerships that have been designed to strengthen specific programs within academic health centers.36 – 40 Other relationships involving U.S. and Canadian schools have focused on particular needs, such as faculty development.41,42 Also—beyond the United States and Canada—several notable collaborations43,44 have strengthened institutions through specific means, such as increasing the quality and quantity of their training programs. However, these and a few other examples are the exceptions; most partnerships have been limited in scope and were not designed to strengthen entire institutions in SSA or their ability to comprehensively improve health in the region.
A Strategic Approach to Strengthening Partnerships
In recognition of the need to explore more effective, more comprehensive, and more balanced—that is, more truly collaborative—approaches to partnerships between medical schools in the United States and SSA, the Bill and Melinda Gates Foundation provided funding for two-year learning grants through what we describe as a “collaborative learning initiative” (or simply collaborative). Before any collaborations received funding, two of us (J.C.K, K.C.) developed 10 learning questions that would help determine if collaborations were structured to improve health systems and health outcomes in SSA. We based the questions on the literature9 – 13 and on informal, one-on-one and group discussions with not only leaders from health science schools in Africa, the United States, and Canada, but also leaders from health ministries in SSA. We sought, through the literature and our conversations, to identify the gaps in our knowledge regarding the structuring of effective academic partnerships that are oriented to improve health. The issues that the stakeholders in SSA and North America most agreed were problematic formed the basis of the learning questions (List 1).
Putting the Learning Questions Into Practice
These learning questions played a central role in deciding which U.S. medical schools would receive funding from the Bill and Melinda Gates Foundation. Twelve U.S. medical schools approached the foundation with an interest in developing partnerships in SSA, and the foundation determined six active partnerships to be most able to address the learning questions. The foundation asked these six to submit full proposals, and an external advisory board helped select the top three proposals for funding. These came from (1) Muhimbili University of Health Sciences, Tanzania, in partnership with the University of California, San Francisco (UCSF), (2) Makerere University, Uganda, in partnership with Johns Hopkins University, and (3) the two major universities in Ghana, University of Ghana and Kwame Nkrumah University of Science and Technology (KNUST), in partnership with the University of Michigan. Of note, these collaborations typically include the African universities' schools of public health, nursing, and allied health sciences.
An essential requirement for successful proposals was involving the ministries of health and of education from SSA in the partnership so as to optimally align education processes with the countries' human resource needs to improve health. Of the posed learning questions (List 1), the first addressing the establishment of a true charter of collaboration was deemed to be the most important to structuring effective partnerships.
Leaders from all the schools involved in all three partnerships began meeting collectively to determine what type of evidence they would use to measure the success of their partnerships. Specifically, they took on the challenge of identifying measures to evaluate the collaboratives in terms of how they work together to strengthen the health science institutions in SSA and improve the health of people living there. Members from partner institutions met semiannually (once in the United States and once in Africa) in 2008, 2009, and 2010 to share best practices and brainstorm potential solutions to common barriers. These meetings, along with subsequent dialogue via e-mail, resulted in five areas of focus for a common evidence framework (List 2).
The opportunity for these leaders to meet and discuss the perceived value from these collaboratives has been a major strength of this initiative. Leaders have shared effective practices both for revising the curriculum on the basis of needs analyses completed by graduates in the workplace and for establishing charters of collaboration between the academic institutions and federal ministries.
Collectively, the partnerships are building an evidence base that demonstrates how the collaboration is linked to better health care and improved health. Although each partnership is different, common elements of success include ownership of the agenda and work plans by the SSA partners, frequent communication among leaders, and a focus on developing local expertise on-site at the SSA institutions.
Specific outcomes from these initiatives are forthcoming; each partnership or collaborative will publish its own findings. However, some evidence has already linked these partnerships to strengthened institutions and improved health in SSA; for example, research at Makerere College of Health Sciences, done in partnership with Johns Hopkins, has helped to inform Ugandan government policy (e.g., mandatory male circumcision to help slow the spread of HIV, and compulsory use of nevirapine during pregnancy to minimize transmission of HIV from mother to child), has resulted in better care for disadvantaged communities (e.g., extending outreach primary care services through a community-based education and service program), and has led to the pilot of an innovative approach meant to increase the rate of safe obstetric deliveries.45,46 The relevant leaders at the University of Ghana, KNUST, and the University of Michigan have co-signed a charter for collaboration, which can serve as a model for other partnerships seeking to establish relationships that aim to strengthen SSA health science schools.47 These partners have also generated and disseminated research on successful models for retaining in Ghana obstetrician–gynecologists, as well as research on incentives for encouraging health care workers to practice in rural areas.48,49 Finally, faculty and leaders from UCSF and Muhimbili University of Health and Allied Sciences have worked with the ministries responsible for health and education in Tanzania as well as other universities in the country to produce an extensive faculty development program and a robust, competency-based curriculum, both of which are heavily informed by stakeholders in the local community.
Recently, U.S. government agencies have increased funding opportunities to support partnerships specifically aimed at strengthening medical and nursing education in SSA.50,51 A central requirement of these proposals—that the principal investigator be based at an SSA institution so that local needs will drive the partnerships—aligns with the learning questions and framework of evidence we have developed to structure and evaluate the three Bill and Melinda Gates collaboratives. Funding agencies and institutions in the North can play a meaningful role in the continued development of accountable medical education systems in SSA by supporting those institutions, researchers, and projects that aim to improve, for the long term, the health of their countries—rather than by undertaking short-term research projects or sponsoring vaguely educational exchange experiences. The value proposition to medical school leaders in the North should extend well beyond receiving extramural funding which, historically, funnels through their institutions on its way to schools in SSA. Real and tangible benefits include participating in innovative approaches to health care in settings with limited resources, increasing faculty satisfaction and providing opportunities for faculty development, building teams and strengthening networks, and helping to find solutions to some of the most pressing health problems. Proposed guidelines,32 along with our learning questions and evidence framework, will help ensure that exchanges between institutions in the North and areas with limited resources such as SSA are structured so as to ensure mutual benefit.
In summary, improving the health of people in SSA is dependent on strengthening medical education in the region. Forming collaborative partnerships with Northern institutions is one strategy for accomplishing this, but SSA institutions must own and drive the agenda, and all partners must carefully evaluate the effectiveness of the partnership.
* The global health community now commonly refers to countries that have more economic resources as the North in part to be more inclusive of Europe which has been very active in global health initiatives.
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The work referred to in this paper was supported by the Bill and Melinda Gates Foundation.
No funding supported the writing of this paper; however, Joseph Kolars worked as a consultant for the Bill and Melinda Gates Foundation. Kathleen Cahill was formerly employed by the same. The remaining authors have all received funding from the Bill and Melinda Gates Foundation to work on learning grants for education collaboratives.