Returning the debt: how rich countries can invest in mental health capacity in developing countries

A number of recent articles (1-3) have highlighted the increasing reliance of developed countries on doctors and nurses trained in much poorer countries. US commentators have noted that "moral outrage over the poaching behavior on the part of the rich countries has reached a crescendo" (4). This year's World Health Report focuses on the subject of the severe shortage of health manpower in many countries, and the role of migration of health workers as one contributing factor (5). This topic has generated controversy and diversity of opinion (1). Nevertheless there are some imperatives: a) recruitment of health professionals from developing countries damages their fragile health systems; b) international medical migration is here to stay and it would be impractical and unethical to block it; c) improvements in working conditions and career structures are required for health professionals in developing countries; and d) developed countries owe a debt to poorer nations and could do more to assist this process of capacity development. Some suggestions have been proposed for building capacity, from developing and licensing clinical training programs to more radical suggestions to compensate the source countries through direct financial investment (1-3). This article highlights examples of efforts made by psychiatrists working in the UK mental health system to "return the debt".

For this destination country, and in this discipline, the unequal distribution of costs and benefits arising from medical migration are particularly stark. The UK stands out from the other big importers of medical expertise in having the highest proportion of doctors from low income countries (6). Among UK consultant psychiatrists, 26.4% in general psychiatry, 32.2% in old age psychiatry, and 58.9% in learning disability were trained overseas (7). While the UK has around 40 psychiatrists per million population, sub-Saharan Africa has fewer than one and India around four per million (8). Yet, India and some sub-Saharan African countries are the most important contributors to the mental health workforce in the UK. The National Health Service's (NHS) International Fellowship Scheme targeted senior consultant psychiatrists, often those working in medical schools, simultaneously undermining clinical resources and the training capacity for the next generation of specialists (9). Inevitably, there are now reports of unfilled vacancies in public mental health services in developing countries (10).

STRATEGIES FOR BUILDING CAPACITY

We sought out examples from UK NHS Trusts and colleagues whom we knew had worked in developing countries to contribute narrative descriptions of their experiences.

Trainee psychiatrists working overseas

Typically these were people who had taken time out from the final stages of their specialist training in the UK to live and work abroad: Melanie Abas (MA) for two and a half years in Harare, Zimbabwe; Jeremy Wallace (JW) for one year in Mbarara, Uganda; Atif Rahman (AR) for two years in Rawalpindi, Pakistan; Lynn Jones (LJ) intermittently for ten years in the Balkans and Kosovo. MA and LJ took time out when arrangements for doing so were relatively informal in the UK. AR and JW applied formally to their Deaneries for permission to take an "out of scheme experience", usually limited to one or two years. MA and JW took unpaid leave from their UK positions and relied upon local salaries. AR was supported with a Wellcome Trust Tropical Medicine Research Training Fellowship. They all held responsible positions in poorly resourced services and sought to develop the services in which they were working and to train specialist and primary care staff.

"I spent two sessions a week supervising colleagues in child psychiatry at the local teaching hospital (the Institute of Psychiatry). This not only helped me keep my clinical skills alive but also enabled me to set up a child and adolescent special interest group that continued to function after the project ended - I still provide supervision through the internet." (AR)

"With funding from the University and the Tropical Health Education Trust (THET), we resumed outreach clinics to rural health centres, teaching medical students in field clinics. We secured funding through THET for an education and support programme to rural health care workers. We invited the medical officers and nurses from strategic primary health centres for a training workshop, and made links with traditional healers." (JW)

"We worked hard as a team to attract local students to psychiatry, through maintaining a high standard of clinical practice and of teaching. I also taught basic psychiatry to rural general health workers, for which guidance in cultural practices and beliefs from a Zimbabwean medical sociologist at the University proved essential. I made links with primary care, and with the main mental health NGO." (MA)

The challenge was to sustain the benefits accruing from these placements after the trainee had returned home.

"Upon completion of my doctorate, I was able to obtain a research Career Development Fellowship from the Wellcome Trust to continue the work in Pakistan. I now supervise three PhD students in Rawalpindi working to develop suitable interventions for depression in low-income populations." (AR)

"Over the decade of Balkan wars I realised that short term crisis interventions made no sense. The Department of Developmental Psychiatry in Cambridge allowed me to take prolonged leave from the final year of my specialist registrar training to work for Child Advocacy International to establish a child psychiatry service in Kosovo (11). For the last two years I have worked full time for International Medical Corps, integrating mental health services into their primary health care capacity building initiatives in Sierra Leone, Chad, Sri Lanka and Indonesia." (LJ)

Consultant psychiatrists working abroad

We elicited narratives from three consultant psychiatrists: Ama Addo (AA), a child and learning disability psychiatrist who worked in Ghana; Michael Radford (MR), an adult psychiatrist who works in Bangladesh; and Jack Piachaud (JP), a learning disability psychiatrist who works in the former Yugoslavia. Although these consultants were only in a position to spend weeks at a time working abroad, they nevertheless developed and sustained valuable long-term commitments.

"Lectures were geared to local conditions after intensive preparatory links with local senior medical staff. Three lectures on Child and Adolescent Psychiatry and Psychiatry of Learning Disability were supplemented with one on Psychosocial Paediatrics after an impromptu contact with the Department of Child Health. The feedback from students and medical staff was very positive, despite the comments about my Scottish accent, and I was offered the post of a part-time (Honorary) Lecturer with a request for annual lecture visits." (AA)

"My first visit to Dhaka affected me deeply and I have been back nine times so far for two to four weeks at a time. Following visits to village projects with various potential partners, we became excited about the inherent strengths of the rural communities to ameliorate and contain problems associated with severe mental illness. We sponsored training for the committee of the Bangladesh Village Doctors' Welfare Association. This has been generously supported by some courageous senior psychiatrists who have grasped the potential of working (against official policy) with village doctors. We have arranged for the translation and printing of a Bangla version of "Where There Is No Psychiatrist" (12) as a vademecum for village doctors and non-medical workers in local NGOs." (MR)

"Our group made contact with a variety of people for training and greater understanding, and eventually made contact with the UNICEF psychosocial programme office in Zagreb. Eight people became involved in a "Help to the Helpers" programme. My own work in Serbia consisted of a series of ten days visits with a psychotherapist colleague starting in 1994 and continuing till 1999. In the first two years we made eight visits. We got to know key organisers of mental health services for children based at the Institute of Mental Health in Belgrade and the University of Novi Sad. We offered an interactive consultancy based on mutual interests, not claiming special expertise. We saw the emergence of programmes on self-esteem, of brief therapeutic interventions, of training for teachers and primary health staff (13)." (JP)

Capacity building through research

Several of the clinical attachments described above included research components. These contributed significantly to sustainable development of mental health capacity (14,15). The work of the 10/66 Dementia Research Group is a specific example of the potential for research capacity building to assist in the development of policy and practice. The UK based coordinating team provided initial training and methodological support for small pilot studies. Dedicated local investigators worked around their busy clinical practice to gather the data. The net result was 2885 interviews in 26 centres from 16 developing countries and a key publication in the Lancet demonstrating the feasibility and validity of the dementia diagnostic protocol (16).

"We are now engaged in a program of populationbased research and testing the effectiveness of an intervention comprising education and training of caregivers, to be delivered by local community health workers. The collaboration between academics and an international non-governmental organization provided an ideal framework for the initiation of our practically orientated research program. Training for research has stimulated local interest in the development of clinical skills in dementia care." (MP)

NHS Trusts supporting links

We elicited narratives on two NHS mental health trusts supporting links with Uganda: the East London and City Mental Health Trust, which supported staff training at the Butabika Hospital, and the Sheffield Care Trust (SCT), which has established links with providers in the Adjumani district, a region which has endured continuing armed conflict since 1986. Both schemes have had support from their Trust Boards, and senior managers from the Trusts have visited Uganda to formulate plans and agreements with local clinicians and hospitals. These developments are supported by the THET, who have helped to apply for and administrate project funds.

"The scheme aims to form a reciprocal relationship between Adjumani and SCT, building on work already done in Adjumani to examine community needs and priorities. The Chief Executive of SCT visited Adjumani to discuss the link and SCT will release staff to work with services in Adjumani for short periods. They supported a sensitisation seminar for local workers and an initiative to support health workers from district primary care facilities. Two week-long workshops for PCOs gave opportunities for over 30 PCOs to get together and share experiences, develop plans for local projects, as well as to update their knowledge and skills." (EO)

DISCUSSION

In this article, we have highlighted ten examples of UK initiated strategies to "return the debt", each representing modest, practical attempts to build mental health capacity in developing countries. These initiatives relied heavily upon the motivation and commitment of individual psychiatrists. There was little direct financial contribution from UK institutions to facilitate the process. Formal partnerships between NHS mental health trusts (17) are notable exceptions to this general rule. Most initiatives described here were funded by research charities, non-governmental organizations, individual donations or the contributions made by developing country institutions. This is despite the obvious reciprocal benefits: UK mental health professionals benefit from having their cultural sensitivity and clinical skills enhanced, and learning from working in less well resourced health systems (18,19).

While our narratives demonstrate some of the approaches to return the debt, much more could be achieved with strategic planning, coordination and funding. Capacity building initiatives need to extend beyond the specialist mental health professional groups (20) to include the community and general health workers at the frontline of primary health care (21). Capacity building should generally be carried out in the developing country, always in collaboration with local institutions and with accreditation from the local ministry so that trained health workers have a clear career path. If health professionals are invited to a rich country, for example to enhance leadership or when there is a marked lack of local skills, such training should be explicitly linked with efforts to ensure the newly skilled practitioners are able to implement these skills upon their return.

Most importantly, we believe that the governments of rich countries which rely on mental health professionals from developing countries have a particular obligation, as the monopoly employer of health practitioners, to establish and fund a framework through which such initiatives may be supported in a more systematic manner. Core funding could be channeled through the ministries of health and individual health management organizations. As a benchmark for estimating the size of this fund, we suggest it should be at least roughly proportionate to the economic savings the rich country enjoys by employing health professionals it has not had to train. In the meantime, the government could do much more to facilitate practitioners to work in developing countries, for example by encouraging employers to release staff on paid longleave or facilitate short-leave in emergency situations such as the recent natural disasters in south Asia.

We welcome the initiative of the Royal College of Psychiatrists (UK) to encourage trainee psychiatrists and retired psychiatrists to work in developing countries, by accrediting up to 12 months of supervised training abroad for the higher specialist training and maintaining a database of developing country institutions which welcome trainees. A link with the non-governmental organization Voluntary Services Overseas may help to provide appropriate placements and also offers a local salary stipend. However, those with dependents and mortgages in their home countries may be deterred. The Wellcome Trust pays UK salaries to its researchers working in developing countries; we think that other rich country employers should do the same for their trainees gaining valuable "out of scheme" experience.

We recommend that consultants, many of whom were trained in developing countries, are able, if they choose, to spend time in developing countries training health workers and assisting in the development of sustainable local services. We are aware of several examples of UK consultants negotiating clauses in their contracts assuring annual paid study leave for this purpose. This individual approach needs formal recognition as a means of returning the debt. Finally, as the era of revalidation dawns on European medical systems, Medical Councils must explore ways of ensuring that doctors who choose to work in developing countries, often in disorganized health systems, are not penalized for their efforts.