Delivering global health
Sachin Jain and colleagues describe a new approach to training global health leaders
In recent years interest in medical practice in poor settings has grown considerably.w1 This growth has been fuelled by recognition of health disparities between poor and rich countries and the allocation of new
money for global health. Between 1999 and 2005 $40.6bn (£20.7bn; €26.6bn) in new funding was committed to global health.w2
Medical schools and junior doctors’ programmes have responded by establishing clinical rotations in poor settings.w3 Although experience in poor settings is important to educate students about global health, the challenges of providing health
care in poor settings require practitioners to learn to think systematically about the delivery of health care. Doctors need
to be trained to consider the strategic, organisational, and structural problems involved in delivery of care. The global
health practitioner must at once be an astute clinician and an effective manager.
Doctors who work in global health need training in what we have called “global health delivery science,” a new discipline
that will combine the study of clinical practice with the managerial skills necessary to effectively deliver care in poor
settings. Along with clinical training in situ and laboratory experience, doctors need to learn how to tackle real problems
in delivering health care in developing countries. Learning through the study of rich, real life case studies will be central
to training in global health delivery science.
New competencies for a new discipline
Although global delivery of health is as diverse as the settings in which care is provided, many problems are consistent among
regions—underdeveloped healthcare infrastructure, shortages in personnel, health illiteracy, inadequate transportation, and
breakdowns in supply chains. Programmes that train practitioners for global health practice need to arm them with the clinical
skills that they need to understand the population served and the diseases treated. However, equally critical are the skills
to organise and manage the delivery of care with limited resources and in complex settings. In settings where human and physical
resources are scarce the careful design of shared infrastructure for delivery is essential.
Prevention and treatment of diseases should not be viewed as a discrete series of interventions but as cycles of care (box)
in which the value of health care—that is, the outcomes for every dollar spent—is maximised.w4 Most training programmes in global health presently focus on clinical training and take an ad hoc approach to training students
to organise delivery of care, if at all.
What are cycles of care?
Cycles of care refers to the concept that we design delivery systems around the full continuum of a disease process across
stages that may include prevention and screening, diagnosis and staging, delaying progression, initiating therapy, continuous
disease management, and recovery.w5 Delivery systems often focus too narrowly on single parts of the care cycle to the exclusion of the others.
Although the scope of the discipline is not fully defined, the science of global health delivery seeks to answer a basic question:
how should care be best organised to deliver value to patients? The science takes a broad view of this question using quantitative
and qualitative approaches and engages management science, operational research, quality improvement, decision analysis, anthropology,
and health services research to increase our understanding of the challenges of the global delivery of health care. Training
programmes in the science will aim to teach practitioners to apply the lessons derived from the intensive study of cases and
frameworks to improve actual practice.
The case method
Our group—the global health delivery project—has worked on the creation of educational programmes that draw on the science
of global healthcare delivery. We use a teaching approach that is modelled on business school-style case studies, which provide
the reader with in-depth exposure to a particular global health setting and a dilemma.
The student must conduct analyses and make choices using information in the case. The information is presented descriptively
and captures the full complexity of the situation so that students are forced to make decisions and analyse the situation
as they might in real world settings. Under the guidance of a faculty member, the class works together to analyse and synthesise
available data and points of view; to define and prioritise goals; and to persuade others who think differently.w6 The case method teaches students how to think strategically and manage complexity in diverse settings in a manner that has
been described as “virtual experiential learning.”
We have developed 10 distinct case studies, with 15 more in development. In early 2008 our group offered a course at the Harvard
School of Public Health. As the body of case studies grows our group will offer additional courses, with an eye towards creating
a new masters programme in global health delivery science that will combine real world practice and classroom based study
of the managerial problems that global health practitioners face. Our intensive study of individual cases has also led to
the identification of important questions that students and staff will investigate through multidisciplinary operational and
clinical research.
Conclusion
Twenty first century leadership in global health will require a new breed of doctors and other healthcare professionals who
are trained to think strategically about the overall challenges of delivering health care in poor settings, not just clinical
interventions. Doctors will need to consider the complexity of delivery of care from multiple approaches—and be effective
in tackling the wide range of clinical and managerial dilemmas that are inherent to successful global practice.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
Sachin H Jain research fellow and resident, internal medicine
sjain@hbs.edu
Rebecca Weintraub instructor in medicine and executive director, internal medicine, and physician
Joseph Rhatigan director, global health equity residency, and assistant professor of medicine
Michael E Porter Bishop William Lawrence university professor and director
Jim Yong Kim chief, division of social medicine and health inequalities, and chair, department of social medicine, and François Xavier
Bagnoud professor of health and human rights
Student BMJ 2008;16:227 | 18
- Kanter, Steven. “Global Health is More Important in a Smaller World.” Academic Medicine. 2008: 83. 115-116.
- Cohen, Jon. “Global Health: The New World of Global Health.” Science. 2006:311, 162-167.
- Furin, Jennifer et al. “A Novel Training Model to Address Health Problems in Poor and Underserved Populations.” Journal of Health Care for the Poor and Underserved. 2006:17, 17-24.
- Kim, Jim Yong. Rhatigan, Joseph. Jain, Sachin. Porter, ME. “From a Declaration of Values to the Creation of Value in Global Health.” Working Paper.
- Michael Porter and Elizabeth Teisberg's 2006 book Redefining Health Care
- Harvard Business School [homepage on the internet]. Boston. 2008. “The Case Method.” Available from: http://www.hbs.edu/case/case-print.html.
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EDITORIALS
Delivering global health
(Sachin Jain and colleagues, June 2008)
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Bibek Koirala
(June 12th, 2008)
MBBS, Institute of Medicine, Nepal bibek_k@hotmail.com
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The article 'Delivering Global Health' made a good reading. The idea floated by the authors is really praiseworthy. That doctors need to have a sound managerial base in order to work in far-flung areas is indeed a good proposition. Sadly, it is nothing new.
The medical college where I did my graduation - Institute of Medicine, Nepal - has been stressing a need for managerial skills among doctors for a long time now. In fact, we had to visit hospitals in several districts all over Nepal for several months while studying in connection with understanding the administrative functions.
We did learn a lot during the field visits. But, when it came to applying the knowledge, we failed miserably. Not because we couldn't, but because we didn't want to. Only a handful of us were willing to go to outlying areas to serve the rural poor, while most were cosying up to the comfort of the big cities and overseas, which is in a way understandable as the perks involved with working in rural areas is hardly on par with that in the cities.
In 2007, I was involved in a study to assess the clinical skills of mid-level health care workers in rural Nepal. While the clinial acumen of these workers was well below par, they were, interestingly, pretty good at administrative jobs. And, they were very much interested in honing their clinical skills if they were provided with such an opportunity.
From the study, what I concluded is that it is better to train mid-level health care workers further so that they can serve the rural community better, while allowing the MBBS doctors to pursue further specialization because they are not going to the rural hinterlands anyway. Once these doctors get their MD degree then they can serve the community better with attractive perks to boot.
Coming back to the article in question, I was dejected when I learned that the authors thought it worthwhile to offer a course at Harvard School of Public Health when what was really needed was to offer such a course in developing countries. I think this step of yours defeats the whole purpose of the course.
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EDITORIALS
Delivering global health
(Sachin Jain and colleagues, June 2008)
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Apildev Neupane
(June 19th, 2008)
4th year medical student, Institute of Medicine apildev@gmail.com
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Sachin Jain should be congratulated for an innovative approach.With a vast majority of global disease burden in poorly resourced setting, it is already too late that modern medical schools put special focus on health care delivery systems in their curricula.His pearl "cycles of care" is a highly valuable principle though according to him for a newer "breed" of doctors,i prefer older health care professionals too.
But still case studies do not reflect the real scenario when it comes to developing countries where, for example, more than 75 patients undergo dermatological consultation in 3 hours in a tertiary care center! Remember the time constraint, poor ventilation in consultation room, patients' understanding of his disease and many other things which are not reflected in the cases, moreover when the cases are MADE in developed countries.
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