Responsible Global Health Engagement: A Road Map to Equity for Academic Partnerships

In this issue of the Journal of Graduate Medical Education, Umoren et al¹ describe a unique, successful, and high-yield approach to ensuring equity and bidirectional exchanges in global health partnerships. The Indiana University-Moi University team should be commended for ensuring that academic partnerships are meeting the needs of both partners, and for doing so in a way that builds capacity long-term. It is clear that the objectives of this reciprocal experience are greater than measuring examination scores and include expanding the traditional definition of an academic community. Perhaps one of the greatest challenges to these exchanges will be evaluations that go beyond the presumed positive impact on the professional careers of the participating foreign physicians. This may ultimately require measuring the long-term impact of this training opportunity on the successful retention of foreign physicians in work critical to their countries, the overall strengthening of the public health sector in these countries, and the quality of health care provided globally.

The focus on reciprocity, and therefore equitable, balanced, bidirectional partnership, is rarely emphasized in global health activities in graduate medical education. Reciprocity is a powerful way that we can show our foreign colleagues that we believe in true partnership. In the project described by Umoren et al, the length of this experience is appropriate and the costs are minor in comparison to the costs academic institutions incur to send trainees abroad.

This program description is a road map for how well-resourced institutions can ensure equity in their global health training programs. Many global health programs are created to respond to the interest of the trainees at the US institution, rather than being created with a defined objective to fill a gap or meet a need for hospitals, institutions, or the public sector in less well-resourced locations around the world. The responsibility of well-resourced institutions is to ensure the advancement of medicine, research, and training globally, not only in their own backyards and for their own trainees.

Academic institutions in the United States and other resource-rich countries should continue to work closely with foreign partners to define responsible global health engagement and the guiding principles that will allow us to move toward a gold standard for global health programs. Some of this has been described in the Center for Strategic and International Studies (CSIS) report The Dramatic Expansion of University Engagement in Global Health.² This report describes key lessons learned from global health partnerships, such as the importance of shared decision making, fair financial arrangements, joint responsibility for publications, and capacity building. Others have proposed creating a field of science in global health, which would build expertise through training in diverse fields to support the strengthening of health systems.³

In addition to these considerations, those developing global health partnerships should regard global health opportunities for US students and residents as important, but not the primary purpose for the partnership. The demand for global health opportunities has skyrocketed in recent years.⁴ Faculty in the United States must guide these partnerships toward a principle goal of supporting the training of foreign health care professionals and strengthening the health systems of foreign countries. To reach this goal, global health opportunities for trainees must be more standardized to ensure that they are ethically sound and meet the needs of foreign institutions.⁵

The guiding principles for responsible global health engagement should provide academic institutions with a road map for success. This road map will be informed by foreign policy and encourage public sector engagement and strengthening in foreign countries. For instance, US-based academic institutions should focus their efforts at transferring expertise and skills on long-lasting capacity building that helps foreign countries to strengthen their government's human resources for health, monitoring and evaluation, research, surveillance, and health management and administration systems. One successful example of such an effort is the Human Resources for Health Program in Rwanda. This program links multiple US-based institutions with Rwandan medical training institutions to enhance the quality of training and volume of trainees toward meeting Rwanda's projected human resources for health needs over the next 8 years.⁶ This program, which includes reciprocal exchanges between Rwandan trainees and US-based institutions, could be replicated in other countries around the world.

The Indiana University-Moi University program, and others like it, could also have positive implications for research collaborations by expanding opportunities for both sides of the partnership. Many resource-poor countries lack experienced researchers who can lead research initiatives and serve as mentors. Collaborations offer a way to build research competencies among our foreign colleagues. One risk, as outlined in the CSIS report, is the unbalanced domination of US-based institutions in research activities because of their extensive resources.⁷ Attention to the guiding principle of reciprocity and a focus on research to build capacity and public sector strength should help to prevent this imbalance.

We need to develop approaches to measure the impact of such experiences on both the participants from the host institution as well as the foreign trainees. Impacts such as retention rates, effects on the public sector, and quality of health care provided are critical areas for study. In addition, impact at the institutional level on both sides of the partnership, effects on brain drain, and the effect on future career paths for both US and foreign graduates are important to investigate.

The Indiana University-Moi University program can serve as a model for equitable, balanced, reciprocal training. This program generates additional questions in global health partnerships: How can this experience be enhanced, what is the impact over time, and how can we expand this approach to other US institutions? Other components that may enhance equity and reciprocity in global health academic partnerships include offering adjunct faculty appointments at host institutions to foreign partners and offering access to academic resources of host institutions. These are natural next steps to extend the bidirectionality of the partnerships and to ensure long-lasting impact and strengthening of the public sector in foreign countries. Future funding for global health programs should be focused on partnerships that meet these key ideals.