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On a busy Tuesday morning, in between his performance in surgery and a multidisciplinary team meeting, I got a chance to talk to Matthijs Botman, plastic surgeon at the VU Medical Centre and global health doctor (formerly called ‘tropical doctor’). Matthijs is the initiator of the Into the World project, a multimedia campaign, and the ‘face’ of the campaign to a wider audience. Recently we saw Matthijs on Dutch television where – sitting beside a former politician and a famous world traveller – he explained why the world ‘needs’ our global health doctors. The format of these shows seldom allows for providing a broad context to the issue at hand, which is why it was appropriate to focus on a few “burning issues”:
- Why are NVTG and the AIGT[1] training institute knocking on the doors of the Dutch Ministry of Health for financial support of the training programme?
- Is there actually a role for the global health doctor in the Dutch health system?
- What are the odds for success and what is the way forward?
But before discussing these issues, let’s look at what inspired Matthijs to set the campaign train in motion. What made him spending much of his free time on meetings preparing the publication, planning with the campaign team, or sitting in a make-up room for yet another public appearance on TV.
Drive
It all started when he was chair of the NVTG working group ‘Global health Doctors in Training’ (TROIE). Matthijs was one of a cohort of medical doctors enrolled in the AIGT training programme for ‘tropical doctor’. The contours of this training had remained relatively unchanged since the early nineties – consisting of clinical internships in gynaecology and surgery, followed by a 3-month public health course – although calls for a change were already being heard. Students and trainers saw the need to revise the training programme within the context of a wider development in which all medical professions were being asked to revise their curriculum in line with the CanMEDS [2] competencies [see also the article on the revised curriculum for the training of the Doctor of Global Health and Tropical Medicine elsewhere in this edition]. Matthijs, at that time hesitating between becoming a fulltime ‘tropical doctor’ or going for a career in surgery, got involved and advocated for a thorough revision of the curriculum of the training programme. His argument was that the training of doctors who dedicate part of their careers to working in low- and middle-income settings needed to undergo the same quality control as any other medical specialisation training programme in the Netherlands – no more no less.
Ministry of health: ‘we need support for…’
And so it happened that the curriculum was revised and the training programme professionalised, largely as a result of the sustained dedication and commitment of a core group of people. In 2012 the training institute was established providing a more solid base for the training programme. However, due to changes in the Dutch health care system, hospitals that had offered clinical internship places started to reconsider their offers. For many years the existing agreements had been silently renewed, mainly out of goodwill. However increasingly hospitals withdrew from the training programme because of lacking compensation for their inputs. The request to the Ministry of Health (VWS) was therefore quite straightforward: include our training programme in the funding scheme for medical specialisation training programmes, which would add up to roughly € 140,000 per student per year (totalling 6 to 8 million per year). Granting this funding would end the dependency of the training programme on the goodwill of hospitals, investments by private donors, and students themselves, who privately invest about € 7000 each in their training. Besides financial sustainability, it would finally be a recognition of the value of retaining this pool of expertise – built up since the 1960s – in the Netherlands and in our globalised world. The Dutch government would be putting the money in a place dear to the hearts of many. Moreover, as Matthijs frames it, ‘Public funding for the AIGT training would be a true commitment to quality, which in the end is priceless. Let quality be our driving force.’
Global health doctors in the Netherlands – a contradiction in itself?
Two times already the Ministry of Health has declined the request for funding and played the ball back to NVTG. Why should they finance a training for doctors who were believed not to directly contribute to the Dutch health system? That would seem a reasonable enough argument, if indeed the global health doctors left after their training and never came back to work in the Dutch health system. But Matthijs – and many other doctors like him – prove this argument wrong. After having worked for some years in the Republic of Congo, he came back to the Netherlands where he continued his medical specialisation and now works as a full-time plastic surgeon in one of our hospitals. Some 30% of those who return from abroad follow suit, another 30% continue as general practitioners (GP), and another 30% find a job working in public health settings (for example in municipal public health departments), as consultants in global health, or as GH policy makers. All contribute to health care and public health in the Netherlands, with an estimated 90% of their further careers being spent in the Netherlands and not in Africa, as the public image would have you believe. So the reality is quite different.
Of course, the issue remains the same. How can the Ministry be convinced of the added value of the global health doctor in the Dutch setting? Richard Smith [see elsewhere in this MTb edition] does not need to think long about the added value of GH doctors. ‘A Ministry of Health in any high-income country can achieve a quadruple win by investing in a global health doctor programme like this one.’ The quadruple win he talks about can easily be explained simply by pointing out the areas where a GH doctor adds his specific expertise. These include migrant health (addressing imported diseases like tuberculosis, malaria, HIV, hepatitis A and B, skin diseases etc.), emerging diseases like Dengue or Leishmaniasis (on the rise as a result of globalisation and climate change), and the emergence of exotic diseases such as Ebola, Marburg, MERS, Zika etc. In many cases they arrive here due to increased global mobility.
What next?
The Dutch Ministry of Health is asking NVTG and the training institute to prove the added value of this new type of medical doctor for the Dutch care system. This is tricky, as we have not been systematically recording and quantifying the added value of being a Doctor+ (a specialist doctor with a global health and tropical medicine view and background). There is a need to present more than anecdotal evidence, preferably hard figures and facts. The challenge is to find ways to measure the added value of aspects such as:
- The positive influence of the ‘GH approach’ on cost-efficient behaviour (for example in referrals in a GP practice or the use of equipment in a hospital setting).
- Being more responsive to the needs of migrant populations who have different cultural backgrounds (for example being able to understand the context where migrants are coming from).
- The hands-on experience that is increasingly needed in travel medicine.
Research is slowly picking up on this. For now, as Matthijs points out, ‘WE HAVE THE REPORTS OF 12 DOCTORS IN THE INTO THE WORLD BOOK AND MANY MORE STORIES, ENDORSEMENTS BY HOSPITAL MANAGEMENT, MEDICAL ASSOCIATIONS, AND THE WIDER PUBLIC ON THE WEBSITE’.
The quest for the structural embedding of AIGT training programme has also gained support from many sides in society and medical professionals. This will help to put the ball firmly back into the court of the Dutch Ministry of Health. And so the dialogue continues
References
- AIGT acronym for Medical Doctor Global Health (global health doctor)
- CanMEDS is an educational framework that describes the abilities physicians require to effectively meet the health care needs of the people they serve / http://canmeds.royalcollege.ca/en/framework
