“Co-producing” Health

Ever since the United States boldly asserted its influence over the international arena in the post-World War II era, the topic of its role in the development and progress of foreign countries has long been debated. This question reaches the U.S. medical profession today as we seek to better understand our role as healthcare providers in a time of growing global interconnectedness. One way of assessing our own international involvement is to evaluate our characterization of the presumed “target population.” Our view of the needs and responsibilities of those we treat abroad dictates our approach to global health.

We often preoccupy ourselves with the logistics of our own medical resources—how many doctors and supplies can we allocate, and how many clinics can we build? Moreover, we too easily view the population at hand as a model of a single disease or condition. We simply declare that we are going to “help HIV patients in Africa” and that becomes our singular goal. Yet this ignores the very social capital and means that are possessed by the persons we seek to help. We overlook the fact that health is not an isolated state of being, but that it is regulated by a series of social, cultural, and even political levers. As such, we should understand people as integral participants in their personal health maintenance and as key components of a larger social network. Earlier this year, Dr. Julio Frenk, Dean of the Harvard School of Public Health as well as the former Minister of Health of Mexico, wrote about expanding our view of global health systems through understanding a person in five different roles: patient, consumer, taxpayer/financier, political citizens, and co-producers of individual and societal health (Frenk, PLoS, 2010). If we do not see global health populations in these contexts, we not only provide an inadequate service but we miss the opportunity to build sustainability and self-sufficiency within the developing society. Such a sentiment is reflected in recent calls to action to develop an “International Health Service Corps” in which health care workers would engage in medical service and capacity-building partnerships abroad as an act of diplomacy (Kerry et al, NEJM, 2010).

Global health involvement of the U.S. is not a question of whether or not we should be involved. In a globalized age, international communication and exchanges are inevitable and necessary. The question is about the particular way in which we are going to partner with the local communities to implement the most effective health interventions and systems possible.  Global health is about how we can make something better overseas than if we had not been involved at all. More importantly, however, it is about how the people abroad can make something better than if they had not been involved at all.

 

Think Local, Act Global: making domestic reform work for global health

I am no expert on domestic healthcare reform and am just beginning to understand better what it involves, but I was very interested in the Affordable Care Act’s efforts to shore up the National Health Service Corps (NHSC), which recruits and supports physicians and other health professionals to work in underserved areas, and expand residency spots in primary healthcare. If done right, the US’s efforts to increase its medical workforce in underserved areas could help to reduce its dependence on foreign medical professionals in these areas, many of whom come from developing countries where there are woefully few medical professionals.

Although the impact of “brain drain” (as opposed to training capacity, for example) is debatable, it is clear that there is a global and growing shortage of HCPs, which has incited enough concern for the WHO to adopt a Global Code of Practice for the international recruitment of health personnel during the last World Health Assembly in May. The code recognizes that international migration of HCPs has several benefits (e.g. professional development, increased income) for individuals and does not purport to halt such migration, but emphasizes that it should have a net positive balance on the health systems of developing countries such that they can retain a skilled health workforce. As we all know, it is veeeeery expensive to train a medical professional, and in most countries this burden falls on states rather than on individuals; thus, the departure of an HCP represents a significant economic loss for a poor country in addition to its effects on the attrition of the health workforce. With a fourth of its physician workforce coming from other countries, the US (as well as other major recruiters of medical personnel such as the UK and Australia), should take a leading role in adopting policies that respect the ideals of the WHO’s code.

There is already some push for the US to invest in workforce development abroad: Congresswoman Barbara Lee has sponsored a Global Health Act, which would support the training of HCPs in developing countries. A former Assistant Surgeon General has also suggested the creation of a Global Service Corps, which would function somewhat like the NHSC and send US medical professionals (including foreign-trained professionals) to developing countries to help facilitate workforce development and the strengthening of health systems. Of course, sending US HCPs abroad through the GSC means that the US will need more medical graduates to replace them. It seems only fair that the US should assume the burden of training the HCPs it will need to fulfill its commitments to domestic and global healthcare to ensure that, in its efforts to provide more equitable access to care, it does not accelerate the attrition of the medical workforce in developing countries. This of course depends not only on the government but also on professional and licensing organizations (e.g., AMA, AAMC) that can help promote domestic training capacity by licensing more medical schools and encouraging existing schools to admit more students.

It is a difficult balance to strike, but hopefully the current and future reform initiatives will allow the US to continue providing opportunities for foreign medical personnel via immigration while assuming its fair share of responsibility (and costs) for the training of its medical workforce.

TODAY: Global HEALTH Act National Call-in Day

From Physicians for Human Rights:

Support the Global HEALTH Act (GHA). Call your Representative today and encourage them to co-sponsor the GHA.

As we celebrate the contributions of nurses worldwide, the health workforce crisis remains one of the greatest hurdles to realizing the right to health for all in developing countries. The GHA can help.

Introduced in Congress by Representative Barbara Lee in March, the GHA would provide $2 billion over five years to increase the number of doctors, nurses, pharmacists and other health workers in developing countries, and to improve primary health care for all.

The bill not only authorizes new resources, it also calls for the creation of a US Global Health Strategy that will complement the goals of developing countries and ensure our aid money is effectively used to save the lives of hundreds of thousands of people. Learn more about the bill on PHR’s blog.

It’s easy to take part in the Global HEALTH Act National Call-in Day. Call the Congressional Switchboard at (202) 224-3121 and ask to be connected to your Representative’s office (if you don’t know who your Rep. is, find out). Then, make your case. Use the script below, and/or bring your own experiences into the call:

Hi, my name is XXX and I live in Town, State. I am calling to encourage Representative XXX to co-sponsor HR 4933, The Global HEALTH Act, which will help fix broken health systems in developing countries. The Global HEALTH Act calls for the development of a US Global Health Strategy to harmonize aid, and provides $2 billion over 5 years to help countries in Africa hire, train and retain more doctors, nurses and other health workers. The Global HEALTH Act will save lives: I hope Rep. XXX will consider co-sponsoring this bill today.