Global health doctors: a view from abroad

PHOTO CAMPAIGN INTO THE WORLD

In the December 28, 2017 issue of BMJ, Richard Smith published a blog in which he makes a case for sustaining the global health doctors training programme in the Netherlands.[1] The training programme is not new to him as he taught on the global doctors programme twice a year for about six years. In this blog, Celebrating the Dutch global health doctors programme, he presents the career paths of some of these global health doctors. By doing so, he aims to present to a wider public the characteristics of this new breed of medical doctors – doctors specialised in tropical medicine who in their daily work in low- and middle-income countries had to deal with every aspect of healthcare, not only clinical work but also drug supply, finances, relating to government, and working with the community.

In his blog, Smith illustrates how these doctors – upon returning to the Netherlands – apply these specific skills and knowledge to their day-to-day work in the Dutch health care context. He also describes the competencies that global health doctors develop during their training and by working in low-income countries. These include an understanding and appreciation of the big picture, realisation of how privileged we are in Europe, flexibility, appreciation of better/more sustainable health systems and models of care, and recognition of the importance of
community, to name just a few. He concludes his blog by adding a fifth win that might convince the government to finance the training programme, namely ‘that the Dutch global health doctor programme is unique and something for the Netherlands to celebrate with pride. It’s a gift from them to the poor world and to themselves‘. Curious about the four other wins? Read about them in Smith’s contribution to the book Into the World: ‘It’s time for the North to learn from the South‘, reprinted on the next pages.

It is time for the North to learn from the South by Richard Smith [2]

In 2006 Lord Crisp stepped down as chief executive of England’s National Health Service (NHS) and went to Africa to see how the NHS could help African health systems. His radical conclusion was that Britain and other high-income countries had more to learn from low-income countries than the other way round. He reported his conclusions in a government report, Global Health partnerships [3], and a highly readable book Turning the World Upside Down [4]. His conclusions mean that health care workers from high-income countries who spend time working in low-income countries may learn much that will benefit health systems in high-income countries – in addition to developing a set of attitudes and skills that are useful anywhere.

Turning the world upside down

Central to Crisp’s argument is the observation that health systems in high-income countries are not sustainable. The United States is already spending more than eighteen percent of its huge gross domestic product on health care, with poor results, and expenditure continues to rise inexorably. The same rise is seen in other high-income countries, and the main drivers are not aging of the population and increasing non-communicable disease (NCD), although these contribute, but the fact the cost of most new health technologies increases faster than inflation. Health care systems in high-income countries are dominated by hospitals and specialists and concentrate on treating people with established disease rather than creating health and preventing disease. They suffer from ‘supply-induced demand’, whereby hospitals fill up, often with patients who may benefit little from the care, and specialists offer an ever-increasing array of treatments, many of which are expensive but add only small benefit. These health systems were developed when patients had mainly acute conditions, but now patients with long-term conditions predominate. Changing these expensive health systems is politically difficult, not least because of large vested interests, but health systems in low-income countries have a chance to do better.

They shouldn’t slavishly follow the path set by high-income countries but should create more sustainable systems, and at least some are doing so. I worked with eleven centres in low and middle-income countries doing research, developing capacity, and advising governments in relation to NCD, and we imagined a system that would be better suited than those in high-income countries for preventing and managing the chronic conditions that dominate in high-income countries and already account for most of the health burden in low and middle-income countries. [5] There should be an emphasis on public health, prevention, and primary care, avoiding what Crisp calls ‘the hegemony of clinical medicine’. Much of care can be standardised and put into protocols that can be delivered predominantly by community health workers, who are often much closer to the people they work with than health professionals. Health care in high-income countries has developed a model where health care is something that is ‘done’ to people by doctors, whereas a more effective model puts the patients in charge. Crisp observes that in high-income countries good health has come to mean doctors, hospitals, and technical treatments, but organisations like BRAC in Bangladesh remind us of the importance of community, family, lifestyles, culture, and behavioural and social factors. Ethiopia is trying to build a system based on health not disease. As well as teaching high-income countries about how to build sustainable health systems, low and middle-income countries also produce innovations that can reduce rather than increase costs. Examples include health workers trained in India specifically to do cataracts who can do dozens in a day; oral rehydration therapy (the standard treatment for childhood diarrhoea) developed in Bangladesh; PACK (Practical Application of Care Kit) developed in South Africa that allows nurses to deliver primary health care [6]; and the use of mobile phones to deliver health care. Innovations may be in technology, systems, policies, how staff are employed, financing, governance, and leadership.

Attitudes and skills learnt in low-and middle-income countries

Many doctors and other health professionals working in health systems in high-income countries are unaware of how their health systems, which are admittedly complex, work; nor do they see ‘the big picture’ which shows that only about ten percent of ‘health’ is accounted for by ‘health care’. Those who work in health systems in low-income countries almost inevitably develop an understanding of the whole system and the big picture. They also come to recognise the privileges of those in high-income countries and when back in high-income countries are less likely to complain and more likely to work to make optimal use of what is available. They recognise the tension between giving high cost care to the few and more moderate care to the many – and are more comfortable with accepting the necessity of prioritising. They can make a little go a long way. Those who work in low-income countries learn to be flexible and adaptable: they have to. They develop a ‘can do’ attitude that will serve them well not just in the work but also in their lives. They are more likely to be effective leaders as they have to lead when there are few others to do so; but at the same time they may become better team players and followers. They learn to work effectively in different cultures, a skill that becomes increasingly important as high-income countries become more multicultural.

Benefits from the Dutch system of training health workers in global health

The Dutch have been far sighted in developing a system of training health workers in global health and have produced what I describe as ‘a quadruple win’! Which I explain below. I taught about non-communicable disease on the Netherlands Course on Global Health and Tropical Medicine at KIT for some seven years, travelling twice a year from London, and I’ve been greatly impressed with the young health workers, most of them doctors, whom I’ve met.
The first win is to the young people themselves. Millennials, as they are called, want meaning and purpose from their work. Everybody wants meaning and purpose from their work, but millennials want them so badly that they will put them ahead of money, status, and career progression. Little or nothing provides more meaning and purpose than working as a health worker and a leader with populations in low- and middle-income countries with people who have little or no access to health care. In contrast, young doctors in the UK and the US – and perhaps in the Netherlands – can find themselves disillusioned working in highly complex health systems in high-income countries with little scope to make much of a difference.

The second win is to people in low- and middle-income countries who benefit from the skills and leadership of the young health workers. Many of the young doctors I’ve met have worked and plan to work with Médecins Sans Frontières in difficult circumstances with people with desperate needs. There is also the benefit to Europeans that by helping people in desperate circumstances the health workers make it less likely that those desperate people will start on the hazardous journey of trying to cross illegally into Europe.

The third win is to the Dutch health system – because most of the young health workers return to work in the Netherlands. They have learnt about how to extract maximum value from health systems, and they have developed leadership skills, resilience, and can-do attitudes that mean that they are better able than health workers who have never worked in low and middle-income countries to rise to the challenges that are growing every day in health systems in high-income countries like the Netherlands.

The fourth win is again to the health workers themselves. Working in the often difficult circumstances of low- and middle-income countries gives people a robustness and resilience that makes it much less likely that they will ‘burn out’ in the stresses of health systems in the Netherlands and other high-income countries. These young health workers may well still be working in 2080 and are likely to have to work into their seventies. It makes a great deal of sense for them to work for five to ten years (or even longer) in low- and middle-income countries.

Conclusions

Surgeons in Britain used to boast of having a “Been to Africa Degree,” by which they meant that they had done a great deal of operating in Africa – often doing operations that they would not be qualified to do in Britain. They no doubt did learn – but it may sometimes have been at the expense of Africans. Now, as Lord Crisp has recognised, doctors and other health workers who work in low-income countries can not only learn much that will make them more effective professionals but they can also learn much that can help create sustainable health systems in their own countries. They, the countries where they work, the Dutch health system, and the Netherlands as a whole all benefit. It’s hard to think of an investment with a better return.

References

1. https://blogs.bmj.com/bmj/2017/12/28/richard-smith-celebrating-the-dutch-global-health-doctors-programme/
2. Into the world. Experiences and views of medical doctors Global Health and Tropical Medicine, Uitgeverij Boekschap and the authors, 2017, p. 142-145. ISBN/EAN: 978-9490357-21-4
3. Crisp N. Global Health Partnerships. London: Central Office for Information, 2007. file:///C:/User/Richard/Downloads/Global%20health%20partnerships%20-%20Crisp%202007.pdf
4. Crisp N. Turning the World Upside Down: the Search for Global Health in the 21st Century. London: RSM Press, 2010.
5. UnitedHealth, National Heart, Lung, and Blood Institute Centers of Excellence. Global response to non-communicable disease. BMJ. 2011;342:d3823. doi: 10.1136/bmj.d3823.
6. Fairall L, Bateman E, Cornick R, et al Innovating to improve primary care in less developed countries: towards a global model BMJ Innovations Published Online First: 23 July 2015. doi: 10.1136/bmjinnov-2015-000045.