Rethinking global health training: making the links between theory and practice

Implication Statement

International medical electives are viewed as an opportunity for medical students to experience global health firsthand and improve cultural humility. Despite its potential benefits, concerns have been raised regarding harms during placements. These need to be addressed to ensure that international electives are conducted ethically and not only benefit learners but also the communities involved. The University of Saskatchewan has transformed its global health certificate, Making the links, in an effort to address existing concerns. We seek to share the program’s approach and its value to us. Other centres may introduce this approach to help train more equity-oriented healthcare workers.

Introduction

International medical electives (IMEs) are an opportunity for medical students to experience global health firsthand in a clinical and cultural context different from their own. They originated in the 1960s and have become commonplace, with some data showing 30% of medical students participating in some form of international elective activity.¹ Supporters of these programs argue that they bolster communication skills, improve cultural competence, and increase employment in underserved communities, all while benefiting those in need. However, there are also critiques that IMEs encourage the complete opposite, and that they reproduce the “very health and social inequities they seek to address.”¹ In this article we showcase an improved approach to IMEs rooted in pre-IME preparation, solidarity and partnership.

One major critique of IMEs is voluntourism, in which medical volunteering primarily results in personal gain through travel opportunities, clinical skill development, and a sense of charity for the provider instead of benefit for the people they serve.² This conflict-of-interest limits students’ ability to acknowledge the potential harms they cause by failing to address the complex needs of the community. Another major concern is that learners may provide care when they are not prepared and thus end up doing more harm than good. Finally, IMEs rarely provide long-lasting impact. This can be due to insufficient time spent in communities and the creation of dependent relationships such that local services are not sustained and supported once the visitors depart.³ Although strongly supported by most Canadian institutions, global health training faces many challenges in the coloniality of medical interventions. Specific ongoing critiques of international medical electives and global health placements include, limited organized community engagement, inadequate methods of student evaluation, and a lack of structured global health offices in many institutions.⁴ Our proposed model could improve global health training at Canadian institutions.

Description of the innovation

The University of Saskatchewan offers a two-year global health certificate program, titled Making the Links, which aims to provide students in healthcare fields with the opportunity to learn about global health through both theory and practice in a way that seeks to address many of the pre-existing global health critiques. Making the Links has scaled back on clinical training, and is grounded in anti-racism, anti-oppression and community engagement.⁴ There are three key differences from previous iterations of the program that define our current approach: 1) critical self-reflection after having done theory-based courses and local placements throughout the certificate, 2) scaling back of clinical learning to focus on advocacy-based work, and 3) structured community engagement experiences. We chose these grounding principles and this approach to prevent negative impacts of IMEs such as the perpetuation of harms, and additionally because of the insufficiency of organized community engagement in the Canadian global health education landscape.^4,5

Outcomes

A central piece of the current program is its emphasis on guided reflective practice. Facilitated discussions with academic mentors allow for inter-peer learning and critical self-reflection as we recognize that failure to understand our own privilege is a major drawback of IMEs. Self-reflection is crucial for developing well-rounded health professionals and plays a key role in improving cultural competence during IMEs.⁵ Figure 1 provides examples of our restructured approach. The program has also shifted its focus significantly from clinically focused learning to advocacy and solidarity-based work, which has helped address concerns about working beyond one’s scope of practice. Theory-based lectures and local Canadian placements occur prior to the IME. Classroom lectures are interwoven throughout the certificate, informing students of key themes in Global Health while providing them with the historical context of health inequities, as recommended for pre-departure sessions.⁵ For example, the 2025 cohort had the opportunity to visit the Cape Coast slave dungeons in Ghana and learn about the medical knowledge that was unjustly extracted during the Transatlantic Slave Trade.⁶ The theory-based courses, local placements and historical experiences ground the discussions and self-reflection in principles of global health solidarity.

Figure 1.

Program logic of revised curriculum

Suggestions for next steps

To introduce our approach into global health curricula, programs should scale back on their emphasis on clinical learning so that the students can focus on patient advocacy, promote self-reflection and theory-based discussions, and include structured community engagement experiences. Developing partnerships with inner-city organisations, and rural Indigenous and international communities fills the gap in the Canadian global health education landscape by providing structured community engagement experiences.⁴ Students often return to our partner sites ensuring continuity. One limitation of our innovation is the resources necessary to implement our model. The University of Saskatchewan has dedicated faculty and resources for the Making the Links program and facilitates its delivery and quality improvement. If a Canadian program already has a strong global health infrastructure, it would be easier to introduce this type of global health certificate. We as learners, as well as our institution, recognize that ceasing to participate in IMEs entirely is not an option. Rather, it is through providing learning opportunities rooted in solidarity and partnership that our goals can be achieved.

Funding Statement

Funding: This study did not receive any funding.

Conflicts of Interest

The authors declare no conflicts of interest

Edited by

Anita Acai (senior section editor); Marcel D’Eon (editor-in-chief)