The Zimbabwe Gecko Society has now partnered with Dr. Ray Markham to implement a healthcare component into the programs we support in individual communities in Zimbabwe. Below is information regarding the project for those interested in helping us support this program.

Project Outline

Zimbabwe/Canada Synergistic Health Improvement Initiative

(ZCSHII)

Whatever you do, work at it with all your heart, as working for the Lord (Col 3:23)

INDEX

1.0 Executive Summary. 3

1.1 Background. 5

1.2 Objectives. 8

1.3 Mission. 8

1.4 Keys to Success. 9

2.0 Start-up Summary. 10

Start-up Funding. 10

Table: Start-up. 10

2.1 Services. 11

2.2 Management Summary. 11

2.3 Personnel Plan. 11

Table: Personnel 11

2.4 Financial Plan. 12

3.0 Important Assumptions. 13

1.0 Executive Summary

This initiative intends to improve health care delivery and the general health of communities in Zimbabwe and Canada by connecting healthcare professionals in these countries and providing mutually beneficial relationships between these groups.

The View:

This project will help develop capacity and improve health care in both countries through a structured process of education, matching skillsets and needs, and co-developing solutions that are sustainable. Multidisciplinary teams from Canada will prepare together and travel to Zimbabwe where they will meet with their peers to co-develop, create and implement practical ways to build-on and improve the health of people in both nations through bi-directional learning and provider development. Where some other initiatives in the Southern Africa have parachuted in services that lacked sustainability, this initiative is grounded on building ongoing capacity and capability within the existing systems. This will be founded on ongoing needs assessments and feedback, and feed forward loops and will demonstrate efficacy though metrics.

The Synergies?

For Zimbabweans: There is a shortage of health care providers, and need for ongoing education/training and support in health care delivery.

For Canadians: Rural health care providers are in low volume high intensity practice. Being exposed periodically to high volume high intensity situations will help maintain crucial skills and comfort, hopefully improving retention (Bissonette, 1994[1]; Thompson et al., 2003[2]; Godkin, 2003[3]; van den Hombergh et al., 2009[4]).

For Both: Developing longitudinal relationships will help support improved professional satisfaction and skills.
The Plan:

Partnering with organisations that have and are developing capacity in the social determinants of health (e.g. Zimbabwe Gecko Society).

Fostering relationships with Ministry of Health, Medical Schools and other relevant partners in the environment facilitating multidisciplinary health care teams (Physician, Nursing, Students, Administrative, Lab, Education, Research etc.) to go from one country to another, initially from Canada to Zimbabwe but potentially bidirectional.

The focus would be on conducting local needs assessment and capacity building activities with some service provision, with the goal of developing accurate and applicable metrics to demonstrate improved health care.

Facilitate longitudinal relationships (e.g. Through the use of technology e.g. video clinics).

The Partners:

Zimbabwe Gecko Society: A Canadian non-profit representing a 20 year history of successful capacity building of the social determinants of health in Zimbabwe in an effective manner, and other Organizations with the same focus.

Zimbabwe Health care providers (Ministry of Health, Medical Schools, Mission Hospitals/clinics)

Canadian Health care providers (Rural Coordination Centre of British Columbia [RCCbc], Continuing Professional Development [CPD] Organizations, Medical Schools, Health Authorities)

Funders/Donors (either financial or in kind e.g. EMRs Smart phones, supplies, time and support).

You.

The Goal:

Healthier Zimbabweans and Canadians through increasing the efficiency of healthcare provision.

1.1 Background

A significant proportion of rural health care providers in Canada, especially physicians, are international medical graduates—a large percentage of whom are from Southern Africa. Among these physicians there is an expressed interest in being able to give back to the countries in which they were trained, but there are many barriers to fulfilling this desire, including geographical separation, doubt about the efficacy and impact of their work, safety concerns, and time constraints (Bissonette, 1994[1]; Ramsey et al., 2004[5]; Seo, 2012[6])

As a rural health care provider who was born in Zimbabwe, did my medical training in South Africa, and now lives and works in rural Canada, I, [Ray Markham] have a great interest in building relationships to improve health care in Canada and in the developing world, starting initially with Zimbabwe.

Within the Canadian health care system there is an increasing awareness of the importance of generalism in rural practice, and furthermore the rural generalist’s unique needs from an educational and skills enhancement perspective. Some of these needs may be best met by being exposed to and participating in medical care in the developing world (Thompson et al., 2003[2]; Drain et al., 2007[7]).

There is an obvious need within the developing world for improving health in general. This should be primarily met by investing in the social determinants of health including clean water, food security, education, and fostering some degree of economic independence, including the empowerment of women in all these areas. There is also significant potential developing relationships within health care provider communities in the developed and the developing world, this will in turn build capacity within the health care system and simultaneously provide benefits to both parties in these relationships (Bissonette, 1994[1]; Thompson et al.[2], 2003; Godkin, 2003[3]; van den Hombergh et al., 2009[4]). There is increasing evidence in the medical literature of the benefits of a stable primary care home. The intent of this project is to leverage relationships and synergies of these relationships to help strengthen generalism and primary care in both Zimbabwe and Canada.

I feel that there would be benefit to partnering with organizations who are addressing or have addressed some of the social determinants of health (e.g. clean water, food security, education, economic independence), and adding in a health care component that would be focused on capacity building in a sustainable manner within the current infrastructure. Moving forward on the premise, I undertook an exploratory trip to Zimbabwe in February/March of 2014 with the intent of seeking out potential partners who are already effectively working on the social determinants of health within Zimbabwe. During this trip I spent time making connections within the health care community to ascertain their perception of the needs and the Zimbabwean perspective of potential areas where synergistic relationships may begin to be developed.

I also met with the Minister of Health [Dr. David Parirenyatwa] at this time, and we were able to discuss this initiative and its goals. Dr. Parirenyatwa expressed interest in pursuing this. His perception was that that this would be best served at a District Hospital level while simultaneously forging links with the universities in Harare and Bulawayo. He was also open to connecting primary care teams of multidisciplinary health care providers from Canada with primary care providers in a focused geographical area within Zimbabwe, with the intent of helping build capacity within the primary care system and developing longitudinal relationships to this end. The intent would not be to foster dependence, but supporting full capacity building where the continuum of care is maintained as the initiative moves on to other areas. He was in support of using metrics to document the efficacy of this within Zimbabwe, and felt that this should include high priority items to the Zimbabwe Ministry of Health, such as maternal and neonatal mortality, as well as metrics that would indicate the efficiency of the system as a whole (e.g. repeat visits, number of patients treated mortality and morbidity measures etc.) as well as the external support services becoming redundant rather than embedded. The details of the focus and what was being measured would depend on the geographical area that was chosen initially as well as the needs and realities of local patients and communities. Dr. Parirenyatwa was open to the use of technology to further enhance longitudinal support. He indicated that he would support developing relationships between students and faculty at both medical schools in Zimbabwe and medical schools in Canada. The Minister highlighted that one of the main barriers to the provision of adequate medical care in rural Zimbabwe is communication (e.g. between healthcare centres and providers). He suggested that this particular barrier should be included and addressed directly during planning.

I subsequently met with the Dean of the Medical School at the University of Zimbabwe, and the Dean of the Medical School in Bulawayo. They are both enthusiastic about developing relationships at a university level and connecting faculty and students in Canada and Zimbabwe. They were most interested in the possibility of remote support for the medical education program. Both Deans expressed that they would fully support medical students and residents coming over to Zimbabwe and have a system in place to do this through the University and that this process could include licensing and other considerations.

I have also had discussions with some members of the Health Professionals Council of Zimbabwe. This Council has a licensing category for Canadian physicians going overseas for educational purposes, and also to do work with non-profits or mission hospitals.

In addition I met with a Dr. Paul Thistle, a Canadian trained and licensed obstetrician and gynecologist who is involved in the surgical program at Karanda Hospital in the north of Zimbabwe. He would support physicians coming over and spending some time at this hospital where there is the potential for skills enhancement in a number of disciplines including general surgery, orthopedic surgery, obstetrics and gynecology, emergency, anaesthetics, infectious diseases [including HIV treatment and tuberculosis treatment], and tropical medicine.

Next steps:

I propose setting up a program by which interested rural physicians in British Columbia would be able to apply to take a team of their choosing to Zimbabwe, and to match them with a skills enhancement opportunity and a capacity-building component best suited to the needs and skills of the team. From the Canadian physician perspective this would have numerous benefits, including developing the knowledge, skills, and abilities outlined in the Royal College CAN meds framework (see section 3.0), not only the Medical Expert role, but also the areas of communication, collaboration, advocacy, management, and scholarship. Before starting the training, the interested health care provider would identify a learning need(s) for himself or herself that, if addressed, would not only improve their own skills and knowledge but also meet the needs and enhance services at home. There would be the potential to conduct an assessment of current status, and impact of engagement in this program. During program implementation, appropriate metrics and indicators developed from the local needs assessment in Zimbabwe would be tracked to demonstrate the efficacy of the program in building local primary care capacity.

I am cautious about preconceiving what this might look like without consulting on the ground; in particular I am reluctant to parachute in a service that outsiders think might be helpful. I believe there is great potential for health care providers in Canada to support healthcare delivery in Zimbabwe as well as supporting medical and allied health professional education. I believe this could also provide potential opportunities for health providers in Canada, namely in clinical skills enhancement, leadership development particularly within the rural context, and enhance generalism in primary care in Canada. We see the potential for sharing learning opportunities in both countries.

In March of 2015 we will bring a team of Physicians, Medical students Nurses, Nurse Practitioners Medical Office assistants, Lab techs (primarily from The Northern Health Authority in BC, Canada) to Zimbabwe to work in an area where Zimbabwe Gecko is actively building capacity in the social determinants of health. We will be going through a pre-deployment education program coordinated by Francis Garwe. My hope for this trip is to focus on building relationships and capacity toward ongoing healthcare improvement in Zimbabwe. It might be as small as a physician taking medical students to an underserved area and developing hands-on skills while simultaneously teaching providers in that area, or it could be larger more hands-on trips with medical teams (docs, nurses, NPs, students, MOAs, lab etc.) from Canada going over and doing similar work in the earlier example, with the added component of team building and leadership development of local physician leads, and/or virtual relationships growing out of these experiences, be it video clinics and treatment to shared medical school lectures /CPD events.

1.2 Objectives

The key objectives for the Zimbabwe/Canada Synergistic Health Improvement Initiative are:

UBC as medical teaching institution seeks to establish enriched learning experiences with a focus in rural medicine for students and learning more on rural health. We will focus our work on rural areas in Zimbabwe with limited services, partnering with organizations that are developing capacity in the social determinants of health.
Build interdisciplinary teams working in collaborative practice. In these teams, professionals work together in a coordinated approach to address the health needs of their Depending on the actual programs and services offered, interdisciplinary teams may include physicians, nurses, nurse practitioners, dietitians, social workers, Diabetes Educators, counsellors, health promoters, community development workers, and administrative staff.
To give the opportunity for Canadian and Zimbabwean Health care providers and medical students’ opportunities to interface in a shared learning environment.
To provide students with excellent professional skills by cooperating with corporate partners and by exposing them to a dynamic and intercultural business environment.
Using developing technology to support these ends, both in the aggregation of metrics, testing the effectiveness of this initiative, and to support longitudinal relationships aimed at capacity building. This would include the use of telemedicine and point of care innovation to enhance care.

1.3 Mission

This initiative intends to improve health care delivery and the general health of communities in Zimbabwe and Canada by connecting healthcare professionals and providing mutually beneficial relationship between these groups.

Zimbabwe/Canada Synergistic Health Improvement Initiative (ZCSHII) undertakes teaching and knowledge exchange in primary care through technological innovations. We embrace the values of integrity, authority, openness, trust and service. These values will be exhibited in the work we do and the way we engage with our stakeholders. We will develop strong connections with the Ministry of Health in Zimbabwe and our community partners to ensure the full integration of services with the delivery of multifaceted health and social services. Integration improves healthcare provider and student training through their practical experiences on the ground. Integration also leads to system efficiencies at the district level where they will be operating.

1.4 Keys to Success

Success will be dependent upon:

Persistent and creative student and preceptor recruitment efforts into the program.
Zimbabwean and Canadian continuous support for the program on a variety of levels.
Readiness and early involvement of the Zimbabwean and Canadian Health services.
Strong financial commitment.
Measurement and demonstration of effectiveness of this initiative.
Provision of supportive infrastructure to allow the providers to work effectively (transportation, accommodation, guidance and mentorship, schedules etc.).
Continuous needs assessment and adaption (feedback loops).
Flexibility within the program to adapt to individual community needs.

2.0 Start-up Summary

To start off the program, we require:

The engagement of key organizations/parties;
$17,500.00 in start-up expenses or in kind donations

Long-term Assets

Computer Hardware

Furniture & Fittings

Set up (open for discussion with the Ministry of Health in Zimbabwe)

Start-up Funding

Each of the founding partners will make an equal/proportional investment in cash or service or logistics requirements of $17, 500 in program start-up costs. All startup expenses and funding requirements are summarized in the tables below.

Table: Start-up

Start-up

Requirements

Start-up Expenses
Project scope and procedure	$0,000
Communication and Liaison	$1,000
Insurance	$500
Website Domain and Hosting	$1,000
Stationary/ other Resources	$500
Office Supplies	$500
Curriculum Development	$10,000
Memberships/Subscriptions (College of Physicians Zimbabwe)	$3,000
Software	$1,000
Rent Computer hardware	$0,000
Total Start-up Expenses	$17,500

2.1 Services

Zimbabwe/Canada Synergistic Health Improvement Initiative (ZCSHII) aims to support healthcare providers and students acquire knowledge and competencies whilst developing their personal and social skills and values in rural medicine. The initiative will aspire to attract preceptors and students to build capacity in the recruitment of highly passionate medical graduates.

We will support students in accordance with educational best practices using the latest technology from diagnostic equipment (e.g. point of care testing) to Telemedicine. We will systematically design and develop processes which produce instructionally sound, engaging programs/curricula aligned with goals and objectives of the initiative.

2.2 Management Summary

Zimbabwe/Canada Synergistic Health Improvement Initiative (ZCSHII) will operate with volunteer staff in the first year, hiring Program Director, Preceptor, and Liaison Consultant as needed. As the initiative grows, additional staff will be brought on board.

2.3 Personnel Plan

Zimbabwe/Canada Synergistic Health Improvement Initiative (ZCSHII) will be formed with three leading partners, a Program Director, Preceptor, and Liaison Consultant. In the first year these people will donate their time to the program.

The Program Director will lead and coordinate the program development and implementation. This person will be primarily responsible for front-end consulting, planning, and project management and overseeing stakeholder engagement the programs administrative functions. The Preceptor will be the lead physician in this program and take responsibility for the quality of the medical care and teaching, including student supervision and practicum application. The Liaison Consultant will be the primary liaison between foreign medical institutions and also with outside stakeholders.

Table: Personnel

Personnel Plan
	Year 1	Year 2	Year 3
Program Director	$20,000	$40,000	$60,000
Preceptor	$60,000	$120,000	$360,000
Liaison Consultant	$20,000	$40,000	$60,000
Total People	3	3	3

Total Payroll	$100.000	$200,000	$480,000

2.4 Financial Plan

The programs financial plan is based on our assumption of achieving desired levels of grant funding and donation of in kind services (Clinician time, equipment support services etc.). Our first-year funding (projected $117,500.00) covering startup expenses and personnel will be sufficient for program kick off.

3.0 Important Assumptions

For Canadian Rural physicians, organizing and running this program offers a significant opportunity for Continuing Professional Development in all CanMEDS Roles

42 % of rural physicians in Canada are internationally trained, with a significant proportion being from Southern Africa. Many are still connected with the countries of their birth and training, and have a desire to use their skills to make a difference.

After stabilizing social determinants of health in a sustainable manner, improving primary care is the most effective avenue to improving health. Zimbabwe Gecko Society is an example of an organization that has a proven track record in being so effective in Capacity building in the social determinants of health as to render themselves redundant in the areas that they have worked. This model should also be translated to Primary care provision.

Building capacity within the existing system is more effective (and more difficult) than parachuting in services. We do not want to go in and develop new systems, rather engage with existing systems and seek their guidance, engagement and input on everything from priorities to practicalities.

Effective and impactful change happens through empowerment of people at the “coal face”. This happens in many ways but starts with a common goal, shared benefits and freedom to get it done. Developing relationships, sharing experience and supporting each other is one way to achieve this.

In the Western world we have a social accountability on the global stage to those less fortunate than ourselves. Certain countries (e.g. Canada) have a particular responsibility given the significant proportion of their healthcare provision being from parts of the world less fortunate
(e.g. Southern Africa).

Care and attention needs to be paid to the ethical manner in which this project is conducted to ensure benefit to sending country, participants(Dumont et al., 2011 [8]) and host country (Crump et al.,2010[9])

Rural physicians in Canada are best suited to lead in this. A part of our particular skillset is being able to do the best we can with what we have at hand, a skill of huge benefit in this exciting opportunity to impact people’s lives in Zimbabwe, while benefiting ourselves and our patients

Both health care systems can improve, the Zimbabwean Health care system from access to health care professionals prepared to listen and be directed by local experts. The Canadian health care system while struggling with sustainability issues has as much to gain from exposing clinicians actively working in their country to a practice of medicine and learning from Zimbabwean expertise and experience (Bissonette, 1994[1]; Thompson et al., 2003[2]; Godkin, 2003[3]; van den Hombergh et al., 2009[4]).

It is important to measure and demonstrate health care improvement throughout this project.

We value evidence (see appendix A: Annotated Bibliography of some relevant articles and Appendix B: Typology of relevant articles).

Ray Markham MBChB, MRCGP, LMCC, CCFP, FCFP Francis N. Garwe, BSc MIS, MAM, MAOM-HCM, CCM

Medical Director Advisor, Organizational Development & Engagement

UBC Rural CPD Northern Health Authority

PO Box 478, Valemount 700-299 Victoria Street, Prince George,

BC, V0E 2Z0 BC, V2I 5B8

Tel: (250) 566 9138 x 2000 Tel: (250) 645-6395

Fax (250) 566 4319 Fax: (250)565.2251

ray.markham@ubc.ca francis.garwe@yahoo.ca or francis.garwe@northernhealth.ca

References:

1] Bissonette, B. 1994. The Educational Effects of Clinical Rotations in Nonindustrialized Countries. Fam Med, 26(4).

2] Thompson M.J, Huntington M.K, Hunt D.D, Pinsky L.E, Brodie J.J. 2003. Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review. Acad Med; 78(3):342–347.

3] Godkin M. A & Savageau J. A. 2003. The effect of medical students’ international experiences on attitudes toward serving underserved multicultural populations. Fam Med, 35.

4] P. van den Hombergh, N. J. de Wit, F. van Balen. 2009. Experience as a doctor in the developing world: does it benefit the clinical and organisational performance in general practice? BMC Family Practice, 10:80.

5] Ramsey, A. H, Haq C, Gjerde, C. L, Rothenberg, D. 2004. Career influence of an international health experience during medical school. Family Medicine; 36(6).

6] Seo, Ha-Neul. 2012. Combining UK general practice with international work – who benefits? British Journal of General Practice.

7] Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. 2007. Global health in medical education: a call for more training and opportunities. Acad Med; 82(3):226-30.

8] Jeffrey, J, Dumont, R. A, Kim, G. Y, Kuo, T. 2011. Effects of International Health Electives on Medical Student Learning and Career Choice: Results of a Systematic Literature Review. Family Medicine, 43:1.

9] Crump, J.A. and Sugarman J. 2010. Ethics and Best Practice Guidelines for Training Experiences in Global Health. Am. J. Trop. Med. Hyg; 83(6).

Appendix A:

Annotated Bibliography of some articles relevant to

International Medical Volunteering

Bissonette, B. 1994. The Educational Effects of Clinical Rotations in Nonindustrialized Countries. Fam Med, 26(4).

Purpose / Hypothesis

The lack of systematic documentation on international rotations for medical students and its presumed positive impact on scope of practice for family physicians prompted this study. The author formally documented the educational impact of medical student’s rotations in international settings and noted implications on family medicine.

Methods

Interviews conducted pre-rotation and a questionnaire consisting of seven short-answer questions and 20 open-ended, short- essay questions given in the last week of rotation. Content analyses were conducted on these interviews to identify and examine recurring themes and domains (93% response rate).

Results

Educational outcomes:
Clinical judgment:

100% reported increase in perceived importance of history and physical examinations in diagnosis
Public health and patient education: 100% reported increased awareness of public health and patient education issues

Cost containment:

78% reported heightened awareness of cost issues

Cultural sensitivity:

57% stated cultural/religious norms played prominent role in health care

Family support:

61% recognized the greater role patients’ families had in host countries in comparison to the US

Career influence:

70% of participants eventually entered residencies in family medicine, general internal medicine, or general paediatrics

Conclusions

Findings show that students who are exposed to international settings in developing countries increases the reliance on clinical skills and cost effective testing practices, which seems to have a direct impact on the career environments post graduation. Based on the experience from those involved in this study, students who are involved in the stated programs are the same students who are better situated and are more likely to be more personally motivated to work in environments that have limited resources.

Miller W. C, Corey G. R, Lallinger G. J, Durack D. T. 1995. International health and internal medicine residency training: the Duke University experience. The American Journal of Medicine; 99.

Purpose / Hypothesis

International experiences have many benefits for medical students (strengthened clinical diagnostic skills, reduced dependence on laboratory testing, experience may lead to changes in career direction, such as careers in preventive medicine or public health, work with disadvantaged populations, or continued interest in international health). Recognizing these benefits, the authors set out to measure the impact of the Duke University Medicine Residency Program.

Methods

A survey was circulated to a mix of students in the residency program from the timeframe of 1988 to 1996. The response rate was 93%.

Results

Participants reported a significant positive impact on their training in internal medicine and their knowledge of tropical medicine. A minority of the nonparticipant group identified a positive effect in these areas as well, namely due to conferences and interactions with their participating colleagues. Participants who changed career plans during residency tended to move toward areas of general internal medicine or public health, in contrast to nonparticipants who tended to change areas of subspecialty or chose private practice. The IHP was identified as a significant factor for selection of the Duke Medicine Residency by 42% of the pre-participant group. Nearly all of the respondents (99%) indicated that the IHP should be continued.

Conclusions

The IHP has a measurable positive impact on the participants, as well as on the Medicine Residency Program. Provide medical students with cross cultural experience in health care, to provide exposure to international health and tropical medicine, and to encourage the development of an appreciation for health care in other parts of the world.

Gupta A, Wells C, Horwitz R, Bia F, Barry M. 1999. The International Health Program: The fifteen year experience with Yale University’s Internal Medicine Residency Program. Am J Trop Med Hyg, 61(6).

Purpose / Hypothesis

The authors’ purpose was to answer the following questions: uncover substantive differences between residents who did or did not participate in the international health electives program with regards to their specialty choices and practice profiles and identify whether participation in international electives had an influence on physicians’ attitudes towards health care.

Methods
Two study groups were derived from Yale-New Haven Medical Center Internal Medicine residents (1982-1996). (352 internal medicine residents: 136 participants in the International Health Program (PIHP) and 216 nonparticipants). The response rate was 61%, with 96 completed surveys in both the participant group and the nonparticipant group.

Results

The most important reasons for participation (score of 7 on a Likert scale) were cross-cultural experience (64%), an opportunity to serve a less privileged population (50%), and experience in a setting with limited resources (41%). The most important reasons for nonparticipation were family (48%) and a desire to do other electives (11%). Residents who did not participate in IHP reported that if they could do it all over, 32% would definitely include an international elective in their residency training and 63% would possibly include one depending on the circumstances.

Conclusions

The findings of this study support the thoughts around the impact of exposure to health care delivery in international settings early in medical training and its impacts on residents. As reflected in the results, international experiences impact attitudes towards health care delivery, especially with regards to the physical examination.

Haq C, Rothenberg D, Gjerde C, Bobula J, Wilson C, Bickley L, Cardelle A, Joseph A. 2000. New World Views: Preparing Physicians in Training for Global Health Work. Fam Med; 32(8).

Purpose / Hypothesis

The authors attempted to determine the impact of international health experiences on physicians in training by studying medical students who participated in an International Health Fellowship Program (IHFP).

Methods

From 1995 to 1996, US medical students were selected to participate in the IHFP, which included training at three US medical schools and at seven medical schools in developing countries. The program included a 2-week preparatory course at a US school and a 6- to 8-week field experience.

Evaluative information was collected from students at four times: on the first day of the preparatory course (baseline), immediately after the course (post course), immediately after the international health field experience (post field), and 1–2 years after the field experience (follow-up). Evaluation instruments included a self-assessment questionnaire containing 64 statements, with a five-response Likert scale and open-ended questions (administered at baseline, post course, and post field) related to international health. A total of 60 students were selected from 145 applicants.

Results

At the end of the fellowship the majority of participants noted that the exposure affected them in the following ways: changed world views; increased cultural sensitivity; enhanced community, social, and public health awareness; enhanced clinical and communication skills; more appropriate resource utilization; changes in career plans; and a greater understanding of the challenges of working in areas with scarce resources. After the international field experience, students strongly agreed with the importance of oral rehydration, communication skills, and patient education. According to student self-assessments, the IHFP significantly improved core medical skills. Ninety-six percent of participants recommended international health experiences for other students.

Conclusions

This study of IHFP fellows demonstrates multiple significant impacts of international health experiences on US medical students in training: the knowledge, attitudes, and skills gained through international health experiences are important for medical practice in the United States and abroad. Given the high interest of medical students in international health and the potential for positive educational impacts, medical schools should increase the availability of high-quality international experiences.

Godkin M. A & Savageau J. A. 2003. The effect of medical students’ international experiences on attitudes toward serving underserved multicultural populations. Fam Med, 35.

Purpose / Hypothesis

US medical students’ participation in international electives is thought to impact the skills that are necessary in serving newcomer and underserved groups in the United States.

Before medical schools can allocate substantial resources for international medical education, the authors set out to provide a valid evaluation of international experiences. This study describes relationships between international experiences and students’ attitudes toward caring for underserved multicultural populations. The study also compares medical student participants and nonparticipants in international electives.

Methods

Self-assessment instrument (pre and post) were used to measure attitudes of 3 groups (1997 to 2003). 146 students before and after participating in international electives; two time intervals for 18 students who completed international electives as preclinical students and 76 class cohorts who did not participate.

Results

Analyses showed that the effect of international experiences can develop and support perceptions and values conducive to serving underserved multicultural populations. These include reported increases in cultural competence and important personal attributes like idealism and enthusiasm. In addition, these experiences can heighten clarity about career roles, including those involving underserved multicultural patients.

Conclusions

This study provides support for the hypothesis and the existing literature that international electives develop attributes that could benefit underserved multicultural populations.

Thompson M.J, Huntington M.K, Hunt D.D, Pinsky L.E, Brodie J.J. 2003. Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review. Acad Med; 78(3):342–347.

Purpose / Hypothesis

Participating in international health electives (IHEs) is reported to provide educational benefits in knowledge (e.g., tropical diseases, cross-cultural issues, public health, alternative concepts of health and disease, and health care delivery), enhanced skills (e.g., problem solving, clinical examination, laboratory expertise, and language), and fostering certain attitudes and values (e.g., idealism, community service, humanism, and interest in serving underserved populations).

The authors endeavoured to evaluate the educational effects of IHEs on participants, by providing a high level literature review of all studies reported in the medical literature that have assessed the effects of IHEs on U.S. and Canadian medical students or residents.

Methods

The authors reviewed all studies reported in Medline and ERIC databases that have assessed the educational effects of IHEs on U.S. and Canadian medical students and residents. Data extracted from eligible studies included type and duration of IHE, details of survey instrument, response rate, comparison group, and outcomes. Seven of the eight eligible studies assessed educational effects on participants using self-reported questionnaires; a single study used an objective measurement of knowledge. Of the 457 studies/citations identified in the research, eight studies met the authors’ criteria. International experience included communities in Africa, Latin America, the Caribbean and a couple of underserved North American settings with durations ranging from three to 32 weeks with six weeks being the norm.

Results

Eight studies involving 522 medical students and 166 residents met inclusion criteria. IHEs appear to be associated with career choices in underserved or primary care settings and recruitment to residency programs. They also appear to have positive effects on participants’ clinical skills, certain attitudes, and knowledge of tropical medicine.

Conclusions

IHEs appear to have positive educational influences on participants’ knowledge, skills, and attitudes.

Furthermore, IHEs may play some role both in recruiting residents and in their choices of careers in primary care and underserved settings. Future directions for research in this field are discussed.

The authors conclude that IHEs clearly play a valuable role in the training of some U.S. and Canadian medical students and residents and suggests that most participants can expect to gain some positive educational benefits from their experiences. They suggest that further effective study designs should follow prospective cohorts of student or resident participants to assess the short- and long-term educational effects of IHEs and compare these effects with the other influences on physicians in training. Other important elements in future research should include suitable controls or comparison curricula, validated survey instruments, and attempts to measure both cost–utility data and long-term effects.

Ramsey, A. H, Haq C, Gjerde, C. L, Rothenberg, D. 2004. Career influence of an international health experience during medical school. Family Medicine; 36(6).

Purpose / Hypothesis

The International Health Fellowship Program (IHFP) ran from 1995-97 and consisted a 6- to 8-week field experience in a developing country. This research adds to the literature analyzing international programs effectiveness assessing the effect of the IHFP on participants’ careers 4 to 7 years after the experience.

Methods

Fellows completed a questionnaire (2001–2002) regarding training, practice setting, patient population, further international work, and knowledge and attitudes about IH. Results were compared with historical data from multiple sources.

Results

Surveys were completed by 42 (70%) IHFP fellows. Breakdown:

46% described their practice environment as inner city, 26% as non-inner-city urban, 23% as rural, and 5% as suburban. 15% work in federally designated Health Professional Shortage Areas.
67% have been involved in community health projects (working in volunteer clinics for immigrants, refugees, victims of torture, indigenous peoples, and the homeless; performing sports physicals and serving as team physicians; directing boards of nonprofit organizations; and giving health-related presentations, staffing health fairs, and mentoring youth.
74% of fellows versus 43% of US physicians were engaged in primary care specialties, including family medicine (36% versus 11%), internal medicine (29% versus 22%), and pediatrics (10% versus 11%).
29% have an MPH degree.
57% have done further work in developing countries, 60% planned on working overseas in the future.
90% named one or more barriers to further IH experiences (common barriers were financial obligations (67%) family concerns (38%), work or practice restrictions (38%), residency restrictions (36%), and lack of opportunities (19%).
67% respondents either agreed or strongly agreed that participation in the IHFP influenced their careers, 33% neither agreed nor disagreed that IHFP participation influenced their careers.

Conclusions

Participation in a structured international health elective, such as the IHFP, may reinforce or increase students’ selection of primary care careers and their commitment to community health and public health and work with medically underserved populations. Medical schools should increase opportunities for, and reduce barriers to, quality international health experiences for students.

Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P. 2007. Global health in medical education: a call for more training and opportunities. Acad Med; 82(3):226-30.

Purpose / Hypothesis

Public Health is a global issue that impacts the health conditions in developed and underdeveloped countries. Physicians are now expected to have a broader understanding of various alternatives and culturally determined medical practices, as well as knowledge of tropical diseases and emerging global infections. The authors attempt to support and rationalize the development of an organization to mobilize U.S. health care workers in the fight against HIV in developing countries.

Results

Those who have completed a rotation in a developing country have reported increased skills and confidence, enhanced sensitivity to cost issues, less reliance on technology, and greater appreciation for cross-cultural communication. They become better clinicians by broadening their clinical exposure and experience, most obviously with regard to diseases that are endemic in developing countries and rarely encountered in the student’s home country. They also learn to practice medicine with limited access to laboratory tests and expensive diagnostic procedures, relying on strengthened physical examination skills and depending less on laboratory values, radiologic imaging, and other diagnostic testing, and they develop a deeper appreciation for global public health issues and become more culturally sensitive.

Conclusions

Medical schools should be encouraged to continue integrating global health teaching into medical curricula while creating and promoting more opportunities for international rotations.

Also, they should move toward making an international clinical rotation a routine part of medical education. The authors also support the collection of more quantitative data on global health in medical education. Teaching the global aspects of medicine and understanding medical resources and care in a developing country will prepare future physicians to have a more complete understanding of health and medicine and will encourage them to pursue primary care specialties and to serve in resource-poor settings strengthening health systems as a whole.

van den Hombergh, N. J. de Wit, F. van Balen. 2009. Experience as a doctor in the developing world: does it benefit the clinical and organisational performance in general practice? BMC Family Practice, 10:80.

Purpose / Hypothesis

Although many countries engage in supporting health care services in developing countries through different forms of international rotations for new physicians (i.e. in hopes of reaping benefits to western health care systems after their return) uncertainty still exists regarding the effectiveness of this practice.

This qualitative study focused on insights from fellows of an International Health Fellowship Program (IHFP) going on the hypothesis that participation in formal or informal international settings had a positive influence on their careers. The relation between ‘medical experience in developing countries’ and the clinical and organisational performance of general practitioners in the Netherlands was studied.

Methods

A retrospective survey (1999 data) using two databases to analyse clinical and organisational performance was used. For clinical performance, a regional database was used. The analysis of organisational performance used the Practice Visit database with the results of the quality assessment method VIP for GPs and their practices developed by the Centre for Quality of Care research. The survey was sent to 517 GPs and analysis was done at the GP level and practice level.

Results

Almost 8% of the GPs had experience in a developing country of at least two years.
Prescription volume of these GPs did not differ from that of their colleagues
GPs with experience in a developing country referred less patients during 1999 as compared to their colleagues
Sociodemographic characteristics did not have an difference on either group.
16% of the practices had a GP or GPs with at least two years’ experience in a developing country. They worked more often in-group and rural practices with less patients, prefer GP and more often part-time. These practices are more hygienic, collaborate more with the hospital and score better on organisation of the practice.

Conclusions

There are some notable differences between GPs with international experience and those without this experience i.e. working in more group practices in rural areas however this does not surprise since these doctors used to work in rural hospitals in developing countries.

The authors are hesitant to attribute the differences seen between GPs with international medical experience from those without medical experience to their time abroad. Other factors that are challenging to isolate such as personal motivations and other related factors may also have an impact.

Crump, J.A. and Sugarman J. 2010. Ethics and Best Practice Guidelines for Training Experiences in Global Health. Am. J. Trop. Med. Hyg; 83(6).

The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) developed a set of guidelines for institutions, trainees, and sponsors of field-based global health training on ethics and best practices in this setting. Because only limited data have been collected within the context of existing global health training, the guidelines were informed by the published literature and the experience of WEIGHT members. The Working Group on Ethics Guidelines for Global Health Training encourages efforts to develop and implement a means of assessing the potential benefits and harms of global health training programs.

Jeffrey, J, Dumont, R. A, Kim, G. Y, Kuo, T. 2011. Effects of International Health Electives on Medical Student Learning and Career Choice: Results of a Systematic Literature Review. Family Medicine, 43:1.

Purpose / Hypothesis

With more and more US based medical students becoming interested in international training (since 2000 to the time of this study, 23.1% of medical students had participated in some form of such training), this study desired to conduct a systematic literature review on international health electives (IHE) and its role on medical student learning and career choice.

Methods

A systematic literature review was conducted identifying key English-language articles on IHEs, using PubMed journal databases covering different time periods, 1997–1998 and 1997–2003, using different evaluation tools and methods. Information on type and duration of IHE, study and comparison group characteristics, and measured outcomes such as self-reported changes in cultural competency, clinical skills, and specialty choice, were extracted and summarized.

Results

Findings suggest that having IHE experiences contributed to a more well-rounded training for medical students; IHEs appeared to offer important opportunities for medical students to strengthen existing skills or learn new diagnostic skills, with less emphasis on the use of “high tech” instruments or interventions and more on history-taking and clinical reasoning; several studies indicated that participation in IHEs increased medical students’ knowledge of tropical disease and immigrant health, suggesting that this experience may help prepare students for treating imported diseases among immigrants or tropical diseases brought home by US travellers in the future. IHE participants were generally more likely than non-participants to report attitudinal changes, such as greater appreciation for the importance of cross-cultural communication (cultural competency), prevention, environmental health, public health interventions, and providing care to the underserved, and several studies showed that IHE participants were more likely than non-participants to choose primary care specialties (eg, family medicine, internal medicine, pediatrics), seek employment in low-income clinics, and/or pursue graduate education in public health

Conclusions

Although IHE experiences appear to have educational benefits, the quality and availability of these electives vary by institution. Barriers to ensuring that students attain a safe and rich experience include the lack of consistent categorical funding, safety concerns when traveling, and limited faculty experience and resources to support and guide students during their rotations abroad.

Henry, J. A, Groen, R.S, Price, R.R, et al. 2012. The benefits of international rotations to resource-limited settings for U.S. surgery residents. Surgery.

Purpose / Hypothesis

There is a recognized interest around international medical rotations and how they can formally be applied to residency training programs. This study set out to assess specific benefits of surgery resident rotations in resource-limited settings with the goal of highlighting implications for formalized international residency rotations.

Methods

In November 2011, surveys were administered to 188 Surgeons Over-Seas (SOS) members via e-mail (members included surgeons, residents, and medical students interested in global surgery). The survey consisted of one question “please identify five reasons why sending U.S. surgery residents to train in areas of need are beneficial” was subsequently categorized and thematic analysis was administered. The response rate was 31% (58 completed surveys).

Four categories of benefits were observed: Educational, Personal, Foreign Institution/Global Surgery, and Home Institution. Subsequently, the themes were linked with the American Accreditation Council for Graduate Medical Education (ACGME) core competencies.

Results

There were fifty themes identified in this study (including the ACGME core competencies), covering topics that captured: learning to optimally function with limited resources, exposure to a wide variety of operative pathology, exposure to a foreign culture, and forming relationships with local counterparts.

Conclusions

This study questioned the role that international rotations play in general surgery residency programs. The 50 themes captured in this study are broad in scope and ultimately encourage formal international rotations as part of surgery training.

Wilson, J. W., Merry, S. P., & Franz, W. B. 2012. Rules of engagement: The principles of underserved global health volunteerism. The American Journal of Medicine, 125, 612–617.

Purpose / Hypothesis

With the growing number of global health volunteer programs, the authors describe principles for engaging in these types of initiatives highlighting the impact of these initiatives on developing countries.

Methods

As underserved health and volunteer programs continue to develop, it becomes increasingly important to establish a set of guiding principles by which to operate. Four fundamental principles offered by the authors include: service, sustainability, professionalism, and safety.

Conclusions

Despite the popularity of medical care volunteerism, focusing on vaccinations, provisions for clean water, and improvements in community hygiene may actually have a larger, more profound, and enduring impact. Such public health projects should be considerations for any undeserved healthcare initiative. The education of local health providers (“train the trainer”) is a key element to ensure a lasting benefit. The establishment of open, trusting, and long-term relationships with the community and its local providers is essential to ensure the appropriateness of underserved health activities and optimize outcomes.

Loh, L. C, Lin, E. C, Lin, H. C, Heckman, J. E, and Rhee, D. S. 2012. Another Global Health Rule of Engagement? The American Journal of Medicine, 126(3).

Response to Wilson et al 2012 article:

General agreement with the principles described in the above article.

Highlights:

Collaboration with local leaders and leaders from other teams identified the Internet as a potential collaboration platform. As a result, an online community is being developed to enhance communications. Tools being developed include an interactive calendar, a contact database, an inventory of supplies on the ground, and a virtual library and forum. The goal is to track long-term goals in real-time, with constant discussion.

Seo, Ha-Neul. 2012. Combining UK general practice with international work – who benefits? British Journal of General Practice.

Purpose / Hypothesis

In the UK there is interest formalizing and encouraging GPs to practice in international settings with a goal of broadening the education of UK healthcare professionals, appreciation of novel ideas for systemic improvement in the NHS, and the building of stronger global partnerships that could enhance the UK’s international position.

Methods

The authors undertook a cross-sectional survey to explore the experiences of over 400 GPs who have combined UK-based general practice and international work.

Results

Responders reported undertaking a wide variety of international work in both high and low-to-middle income settings, often at times of transition between different roles. Many responders incorporated work overseas into their GP training as out-of-programme activity, while others worked abroad during natural breaks between career changes or career stages. Some GP partners used sabbaticals as opportunities to undertake international work.

Responders reported developing a range of competencies via the experience of international work, which could be transferred back to the UK setting to a variable degree.
An important finding from the survey was that international work was reported to affirm responder’s specialty choice of general practice as a career as well as have a positive impact on NHS work by renewing enthusiasm on return to the UK.
Responders developed further skills in teaching, research, and public health, with some pursuing further relevant qualifications such as advanced degrees and GP trainer accreditation.
Many responders expressed increased desire to undertake more international work and/or decisions to serve multicultural populations while in the UK.
The majority of responders planned to combine a career predominantly based in UK general practice with some international work in the future. Specific examples of international work that responders envisaged in prospective careers included teaching, humanitarian work, and clinical service delivery in low-income countries.
A minority of responders reported negative effects of undertaking international work, primarily in relation to relinquishing GP partnerships prior to work abroad and perceived difficulty in obtaining substantive posts or even any clinical work on subsequent return to the UK. Responders’ concerns regarding recognition of work done abroad and revalidation in the UK are comparable to issues highlighted in a study of doctors volunteering overseas.

UK healthcare professionals are increasingly likely to seek opportunities to undertake work overseas in addition to the UK. A growing body of evidence suggests that international work can be beneficial to the NHS by providing a context to develop competencies that are valuable to both UK healthcare professionals individually, and systemically to health services.

Conclusions

Acknowledging the potential value and assist health professionals with respect to work opportunities abroad is supported in this study. To realise optimal gains from GPs who have undertaken international work, health policy makers, and organisational bodies, clinical commissioning groups, and GP practices could consider facilitating GP roles that combine clinical work with service improvement responsibilities.

Loh, L. C & Lin, H. C. 2014. Potential Benefits of Collaboration in Short-Term Global Health Learning Experiences. Academic Medicine; 89 (4 ).

Crowdsourcing has been proven to be effective across medical fields (online-based collaboration platforms). The authors analyse the effectiveness of the “crowdsourcing” model as a method to coordinate multiple short-term overseas educational programs that offer cohesive longitudinal efforts (impact-driven global health education and engagement, novel collaborative approaches provide important avenues to harnessing the collective strengths of medical professionals, institutions, and trainees).

Crowdsourcing may offer a number of potential benefits, including (1) eliminating redundancies and improving efficiency, (2) developing consistent program goals, (3) bridging discontinuity in the provision of local care, and (4) improving innovation with diverse sets of eyes and perspectives.

Things to consider with this model:

Challenges establishing program continuity as cycles support the constant flow of new groups (having full-time staff may mitigate this)
Program evaluation and developing routine quality improvement mechanisms

Ferrara B. J, Townsley E, MacKay C. R, Lin H. C, Loh L. C. 2014. Short-term global health education programs abroad: disease patterns observed in Haitian migrant communities around La Romana, Dominican Republic. Am J Trop Med Hyg; 00(0).

Purpose / Hypothesis

Haitian communities commonly receive healthcare through mobile medical clinics that provide primary care services. These clinics are staffed by visiting short-term teams from the United States and/or Canada and commonly consist of physicians, nurses, pharmacists, other allied health professionals, and public health professionals as well as healthcare trainees.

This study describes the health status of a population served by a short-term experience conducted by a North American institute, and the results of a retrospective review are used to identify commonly encountered diseases and discuss their potential educational value.

Methods

Data was collected from patient encounters that took place in 13 separately conducted clinics during a series of medical trips from the same institution in 2011 and 2012. The primary goal of these trips was to expose medical students to primary care work abroad while providing an opportunity to volunteer. Teams were made up of 16–20 individuals and included medical students in their clinical years, nurses, allied health professionals, and faculty leaders. Chart information selected for review included demographics (age, sex, weight, heart rate, and blood pressure), presenting symptoms and signs, diagnoses, and treatments provided. In total, 1,063 encounter cards from 13 days of clinic in 13 bateyes from March of 2011 and 2012 were coded.

Results

Overall, the vast majority of the diagnoses made by short-term visiting teams to the bateyes of La Romana closely paralleled the diagnoses made in a primary care clinic in developed countries.

Khan, O. K, Evert, J, Loh. L et al. 2014. Beyond ‘medical missions’: impact-driven Short-Term Experiences in Global Health (STEG) Principles and Recommendations for Learners and Practitioners. Poster: Child, Family, Health International.

Purpose

Although there are increasing demands for global health (GH) education in medical training such efforts might worsen global health inequities and cause harm. Educators must retool such experiences into academically informed, multi-disciplinary efforts

Motivations

Participants in Short-Term Experiences in Global Health (STEG) may have multiple objectives: education; social responsibility; medical service; or adventure/tourism. STEG provide significant educational gains that are foundational for globally engaged healthcare workers from the Global North.

Common objectives for US medical trainees may include: exposure to conditions not seen in the US; increased clinical acumen; development of professional networks; fulfilling a social responsibility; opportunity to provide care to those in need. Sole focus on clinical care may constrain the broader aim of development and public health if not tied in with capacity-building agenda. Program design should ensure that educational aims are met while acknowledging the limitations of STEG as mechanisms for sustainable global health gains.

Four Principles for Short-Term Experiences in Global Health (STEG)

Principle 1: It is imperative to embed STEG within an organization’s broader community development efforts focusing on upstream, capacity-building approaches.
Principle 2: STEG must foster bi-directional relationships.
Principle 3: STEG should focus on addressing local needs and building on strengths as determined by the host community. Volunteers should be given tasks commensurate with their training in a manner that does not compromise the local community.
Principle 4: Humility and cultural competency are critical components of developing and sustaining a successful short-term experience in global health.

Appendix B:

Typology of some articles relevant to

International Medical Volunteering

Study	1994 Bissonette and Route Family Medicine “The Educational Effect of Clinical Rotations in Nonindustrialized Countries”	1995 Miller, Corey, Lallinger & Durack. The American Journal of Medicine “International health and internal medicine residency training: the Duke University experience”	1999 Gupta, Wells, Horwitz, Bia & Barry. American Society of Tropical Medicine and Hygiene The International Health Program: The fifteen year experience with Yale University’s Internal Medicine Residency Program.
Selection Process	Good academic standing; if able to describe where the student wants to go and why in a preliminary interview; agree to provide data; and able to meet criteria of rotation host		Two study groups were derived from Yale-New Haven Medical Center Internal Medicine residents (1982-1996). (352 internal medicine residents: 136 participants in the International Health Program (PIHP) and 216 nonparticipants)
Assessment Tool/ Purpose	Interviews conducted pre-rotation and a questionnaire consisting of seven short-answer questions and 20 open-ended, short- essay questions given in the last week of rotation.	A survey was circulated to a mix of students in the residency program from the timeframe of 1988 to 1996.	Surveys were administered to the groups.
Study Group/ School Year	Fourth year (n=28)
Findings	Educational outcomes: Clinical judgment: 100% reported increase in perceived importance of history and physical examinations in diagnosis Public health and patient education: 100% reported increased awareness of public health and patient education issues Cost containment: 78% reported heightened awareness of cost issues Cultural sensitivity: 57% stated cultural/religious norms played prominent role in health care Family support: 61% recognized the greater role patients’ families had in host countries in comparison to the US Career influence: 70% of participants eventually entered residencies in family medicine, general internal medicine, or general paediatrics	Participants reported a significant positive impact on their training in internal medicine and their knowledge of tropical medicine. A minority of the nonparticipant group identified a positive effect in these areas as well, namely due to conferences and interactions with their participating colleagues. Participants who changed career plans during residency tended to move toward areas of general internal medicine or public health, in contrast to nonparticipants who tended to change areas of subspecialty or chose private practice. The IHP was identified as a significant factor for selection of the Duke Medicine Residency by 42% of the pre-participant group. Nearly all of the respondents (99%) indicated that the IHP should be continued.	The most important reasons for participation (score of 7 on a Likert scale) were cross-cultural experience (64%), an opportunity to serve a less privileged population (50%), and experience in a setting with limited resources (41%). The most important reasons for nonparticipation were family (48%) and a desire to do other electives (11%). Residents who did not participate in IHP reported that if they could do it all over, 32% would definitely include an international elective in their residency training and 63% would possibly include one depending on the circumstances.

Cont.

Study	2000 Haq et al. Family Medicine “New World Views: Preparing Physicians in Training for Global Health Work”	2003 Godkin and Savageau Family Medicine “The Effect of Medical Students’ International Experiences on Attitudes Toward Serving Underserved Multicultural Populations”	2003 Thompson, Huntington, Hunt, Pinsky, & Brodie. Academic Medicine “Educational effects of international health electives on U.S. and Canadian medical students and residents: a literature review”
Selection Process	Applicant required to be in good standing. Application included: essay regarding interest and motivations for international, community, and cross-cultural health training, brief community health project, and two letters of recommendation; participants selected based on commitment to international, cross-cultural, or community-oriented primary health care and letters of recommendation	Application: student must be in good academic standing and agree to a site considered appropriate by director; nearly all applicants were accepted	The authors reviewed all studies reported in Medline and ERIC databases that have assessed the educational effects of IHEs on U.S. and Canadian medical students and residents. Data extracted from eligible studies included type and duration of IHE, details of survey instrument, response rate, comparison group, and outcomes.
Assessment Tool/ Purpose	Students polled before and immediately after preparatory course, immediately after elective, and 1–2 years after elective with self-assessment questionnaire containing 64 statements (98%).	Self-assessment instrument (pre and post) were used to measure attitudes of 3 groups (1997 to 2003).146 students before and after participating in international electives	Seven of the eight eligible studies assessed educational effects on participants using self-reported questionnaires; a single study used an objective measurement of knowledge. Of the 457 studies/citations identified in the research, eight studies met the authors’ criteria. International experience included communities in Africa, Latin America, the Caribbean and a couple of underserved North American settings with durations ranging from three to 32 weeks with six weeks being the norm.
Study Group/ School Year	Fourth year (n=59)	Two time intervals for 18 students who completed international electives as preclinical students and 76 class cohorts who did not participate
Findings	At the end of the fellowship, a majority of participants noted that the exposure affected them in the following ways: changed world views; increased cultural sensitivity; enhanced community, social, and public health awareness; enhanced clinical and communication skills; more appropriate resource utilization; changes in career plans; and greater understanding of the challenges of working in areas with scarce resources. According to student self- assessments, the elective helped to significantly improve core medical skills (P<.01). 83% of the students said the experience changed how they practiced medicine 96% of the students recommended international health electives to other students 80% of the students planned to primarily practice in the US and spend some time overseas	Analyses showed that the effect of international experiences can develop and support perceptions and values conducive to serving underserved multicultural populations. These include reported increases in cultural competence and important personal attributes like idealism and enthusiasm. In addition, these experiences can heighten clarity about career roles, including those involving underserved multicultural patients.	Eight studies involving 522 medical students and 166 residents met inclusion criteria. IHEs appear to be associated with career choices in underserved or primary care settings and recruitment to residency programs. They also appear to have positive effects on participants’ clinical skills, certain attitudes, and knowledge of tropical medicine. IHEs appear to have positive educational influences on participants’ knowledge, skills, and attitudes. Furthermore, IHEs may play some role both in recruiting residents and in their choices of careers in primary care and underserved settings.

Cont.

Study	2004 Ramsey at al Family Medicine “Career Influence of an International Health Experience During Medical School” (Follow-up study to Haq et al in 2000)	2007 Drain, Primack, Hunt, Fawzi, Holmes, & Gardner. Academic Medicine “Global health in medical education: a call for more training and opportunities”	2009 van den Hombergh, de Wit, & van Balen. BMC Family Practice “Experience as a doctor in the developing world: does it benefit the clinical and organisational performance in general practice?”
Selection Process	Applicant selected based on commitment to international, cross- cultural, or community-oriented primary health care and letters of recommendation		A retrospective survey (1999 data) using two databases to analyse clinical and organisational performance was used. For clinical performance, a regional database was used. The analysis of organisational performance used the Practice Visit database with the results of the quality assessment method VIP for GPs and their practices developed by the Centre for Quality of Care research.
Assessment Tool/ Purpose	Survey administered 4-7 years after elective experience (2001–2002). Results compared with historical data from multiple sources (70% among study group).	Those who have completed a rotation in a developing country have reported increased skills and confidence, enhanced sensitivity to cost issues, less reliance on technology, and greater appreciation for cross-cultural communication. They become better clinicians by broadening their clinical exposure and experience, most obviously with regard to diseases that are endemic in developing countries and rarely encountered in the student’s home country. They also learn to practice medicine with limited access to laboratory tests and expensive diagnostic procedures, relying on strengthened physical examination skills and depending less on laboratory values, radiologic imaging, and other diagnostic testing, and they develop a deeper appreciation for global public health issues and become more culturally sensitive.	The survey was send to 517 GPs and analysis was done at the GP level and practice level.
Study Group/ School Year	Students, fourth-year (n=42)
Findings	46% described their practice environment as inner city, 26% as non-inner-city urban, 23% as rural, and 5% as suburban. 15% work in federally designated Health Professional Shortage Areas. 67% have been involved in community health projects (working in volunteer clinics for immigrants, refugees, victims of torture, indigenous peoples, and the homeless; performing sports physicals and serving as team physicians; directing boards of nonprofit organizations; and giving health-related presentations, staffing health fairs, and mentoring youth. 74% of fellows vs 43% of US physicians were engaged in primary care specialties, including family medicine (36% versus 11%), internal medicine (29% versus 22%), and pediatrics (10% versus 11%). 29% have an MPH degree. 57% have done further work in developing countries, 60% planned on working overseas in the future. 90% named one or more barriers to further IH experiences (common barriers were financial obligations (67%) family concerns (38%), work or practice restrictions (38%), residency restrictions (36%), and lack of opportunities (19%). 67%) respondents either agreed or strongly agreed that participation in the IHFP influenced their careers, 33% neither agreed nor disagreed that IHFP participation influenced their careers.	Medical schools should be encouraged to continue integrating global health teaching into medical curricula while creating and promoting more opportunities for international rotations. Also, they should move toward making an international clinical rotation a routine part of medical education. The authors also support the collection of more quantitative data on global health in medical education should be collected. Teaching the global aspects of medicine and understanding medical resources and care in a developing country will prepare future physicians to have a more complete understanding of health and medicine and will encourage them to pursue primary care specialties and to serve in resource-poor settings strengthening health systems as a whole.	Almost 8% of the GPs had experience in a developing country of at least two years. Prescription volume of these GPs did not differ from that of their colleagues GPs with experience in a developing country referred less patients during 1999 as compared to their colleagues Sociodemographic characteristics did not have an difference on either group. 16% of the practices had a GP or GPs with at least two years’ experience in a developing country. They worked more often in-group and rural practices with less patients, prefer GP and more often part-time. These practices are more hygienic, collaborate more with the hospital and score better on organisation of the practice.

Cont.

Study	2010 Crump and Sugarman. American Society of Tropical Medicine and Hygiene “Ethics and Best Practice Guidelines for Training Experiences in Global Health.”	2011 Jeffrey, Dumont, Kim & Kuo. Family Medicine “Effects of International Health Electives on Medical Student Learning and Career Choice: Results of a Systematic Literature Review.”	2012 Henry, Groen, Price et al. Surgery “The benefits of international rotations to resource-limited settings for U.S. surgery residents.”
Selection Process
Assessment Tool/ Purpose		A systematic literature review was conducted identifying key English-language articles on IHEs, using PubMed journal databases covering different time periods, 1997–1998 and 1997–2003, using different evaluation tools and methods. Information on type and duration of IHE, study and comparison group characteristics, and measured outcomes such as self-reported changes in cultural competency, clinical skills, and specialty choice, were extracted and summarized.	In November 2011, surveys were administered to 188 Surgeons Over-Seas (SOS) members via e-mail (members included surgeons, residents, and medical students interested in global surgery). The survey consisted of one question “please identify five reasons why sending U.S. surgery residents to train in areas of need are beneficial” was subsequently categorized and thematic analysis was administered. The response rate was 31% (58 completed surveys).
Study Group/ School Year
Findings	The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) developed a set of guidelines for institutions, trainees, and sponsors of field-based global health training on ethics and best practices in this setting. Because only limited data have been collected within the context of existing global health training, the guidelines were informed by the published literature and the experience of WEIGHT members. The Working Group on Ethics Guidelines for Global Health Training encourages efforts to develop and implement a means of assessing the potential benefits and harms of global health training programs.	Findings suggest that having IHE experiences contributed to a more well-rounded training for medical students; IHEs appeared to offer important opportunities for medical students to strengthen existing skills or learn new diagnostic skills, with less emphasis on the use of “high tech” instruments or interventions and more on history-taking and clinical reasoning; several studies indicated that participation in IHEs increased medical students’ knowledge of tropical disease and immigrant health, suggesting that this experience may help prepare students for treating imported diseases among immigrants or tropical diseases brought home by US travellers in the future, IHE participants were generally more likely than non-participants to report attitudinal changes, such as greater appreciation for the importance of cross-cultural communication (cultural competency), prevention, environmental health, public health interventions, and providing care to the underserved, and several studies showed that IHE participants were more likely than non-participants to choose primary care specialties (eg, family medicine, internal medicine, pediatrics), seek employment in low-income clinics, and/or pursue graduate education in public health.	There were fifty themes identified in this study (including the ACGME core competencies), covering topics that captured: learning to optimally function with limited resources, exposure to a wide variety of operative pathology, exposure to a foreign culture, and forming relationships with local counterparts.

Cont.

Study	2012 Wilson, Merry, & Franz. The American Journal of Medicine “Rules of engagement: The principles of underserved global health volunteerism.”	2012 Loh, Lin, E, Lin, H, Heckman, and Rhee The American Journal of Medicine “Another Global Health Rule of Engagement? “ (In response to Wilson et al study in 2012)	2012 Seo, Ha-Neul. British Journal of General Practice “Combining UK general practice with international work – who benefits?”
Selection Process
Assessment Tool/ Purpose	As underserved health and volunteer programs continue to develop, it becomes increasingly important to establish a set of guiding principles by which to operate. Four fundamental principles offered by the authors include: service, sustainability, professionalism, and safety.		The authors undertook a cross-sectional survey to explore the experiences of over 400 GPs who have combined UK-based general practice and international work.
Study Group/ School Year
Findings	Despite the popularity of medical care volunteerism, focusing on vaccinations, provisions for clean water, and improvements in community hygiene may actually have a larger, more profound, and enduring impact. Such public health projects should be considerations for any undeserved healthcare initiative. The education of local health providers (“train the trainer”) is a key element to ensure a lasting benefit. The establishment of open, trusting, and long-term relationships with the community and its local providers is essential to ensure the appropriateness of underserved health activities and optimize outcomes.	General agreement with the principles described in the Wilson 2012 article. Main Points: Collaboration with local leaders and leaders from other teams identified the Internet as a potential collaboration platform. As a result, an online community is being developed to enhance communications. Tools being developed include an interactive calendar, a contact database, an inventory of supplies on the ground, and a virtual library and forum. The goal is to track long-term goals in real-time, with constant discussion.	Responders reported undertaking a wide variety of international work in both high and low-to-middle income settings, often at times of transition between different roles. Many responders incorporated work overseas into their GP training as out-of-programme activity, while others worked abroad during natural breaks between career changes or career stages. Some GP partners used sabbaticals as opportunities to undertake international work. Responders reported developing a range of competencies via the experience of international work, which could be transferred back to the UK setting to a variable degree. An important finding from the survey was that international work was reported to affirm responder’s specialty choice of general practice as a career as well as have a positive impact on NHS work by renewing enthusiasm on return to the UK. Responders developed further skills in teaching, research, and public health, with some pursuing further relevant qualifications such as advanced degrees and GP trainer accreditation. Many responders expressed increased desire to undertake more international work and/or decisions to serve multicultural populations while in the UK. The majority of responders planned to combine a career predominantly based in UK general practice with some international work in the future. Specific examples of international work that responders envisaged in prospective careers included teaching, humanitarian work, and clinical service delivery in low-income countries. A minority of responders reported negative effects of undertaking international work, primarily in relation to relinquishing GP partnerships prior to work abroad and perceived difficulty in obtaining substantive posts or even any clinical work on subsequent return to the UK. Responders’ concerns regarding recognition of work done abroad and revalidation in the UK are comparable to issues highlighted in a study of doctors volunteering overseas. UK healthcare professionals are increasingly likely to seek opportunities to undertake work overseas in addition to the UK. A growing body of evidence suggests that international work can be beneficial to the NHS by providing a context to develop competencies that are valuable to both UK healthcare professionals individually, and systemically to health services.

Cont.

Study	2014 Loh & Lin. Academic Medicine Potential Benefits of Collaboration in Short-Term Global Health Learning Experiences.	2014 Ferrara, Townsley, MacKay, Lin & Loh. American Society of Tropical Medicine and Hygiene “Short-term global health education programs abroad: disease patterns observed in Haitian migrant communities around La Romana, Dominican Republic.”	2014 Khan, Evert, Loh. L et al. Child, Family, Health International “Beyond ‘medical missions’: impact-driven Short-Term Experiences in Global Health (STEG) Principles and Recommendations for Learners and Practitioners. Poster.”
Selection Process
Assessment Tool/ Purpose		Data was collected from patient encounters that took place in 13 separately conducted clinics during a series of medical trips from the same institution in 2011 and 2012. The primary goal of these trips was to expose medical students to primary care work abroad while providing an opportunity to volunteer. Teams were made up of 16–20 individuals and included medical students in their clinical years, nurses, allied health professionals, and faculty leaders. Chart information selected for review included demographics (age, sex, weight, heart rate, and blood pressure), presenting symptoms and signs, diagnoses, and treatments provided. In total, 1,063 encounter cards from 13 days of clinic in 13 bateyes from March of 2011 and 2012 were coded.	Participants in Short-Term Experiences in Global Health (STEG) may have multiple objectives: education; social responsibility; medical service; or adventure/tourism. STEG provide significant educational gains that are foundational for globally engaged healthcare workers from the Global North. Common objectives for US medical trainees may include: exposure to conditions not seen in the US; increased clinical acumen; development of professional networks; fulfilling a social responsibility; opportunity to provide care to those in need. Sole focus on clinical care may constrain the broader aim of development and public health if not tied in with capacity-building agenda. Program design should ensure that educational aims are met while acknowledging the limitations of STEG as mechanisms for sustainable global health gains.
Study Group/ School Year
Findings	Crowdsourcing has been proven to be effective across medical fields (online-based collaboration platforms). The authors analyse the effectiveness of the “crowdsourcing” model as a method to coordinate multiple short-term overseas educational programs that offer cohesive longitudinal efforts (impact-driven global health education and engagement, novel collaborative approaches provide important avenues to harnessing the collective strengths of medical professionals, institutions, and trainees). Crowdsourcing may offer a number of potential benefits, including (1) eliminating redundancies and improving efficiency, (2) developing consistent program goals, (3) bridging discontinuity in the provision of local care, and (4) improving innovation with diverse sets of eyes and perspectives. Things to consider with this model: Challenges establishing program continuity as cycles support the constant flow of new groups (having full-time staff may mitigate this) Program evaluation and developing routine quality improvement mechanisms.	Overall, the vast majority of the diagnoses made by short-term visiting teams to the bateyes of La Romana closely paralleled the diagnoses made in a primary care clinic in developed countries.	Four Principles for Short-Term Experiences in Global Health (STEG) Principle 1: It is imperative to embed STEG within an organization’s broader community development efforts focusing on upstream, capacity-building approaches. Principle 2: STEG must foster bi-directional relationships. Principle 3: STEG should focus on addressing local needs and building on strengths as determined by the host community. Volunteers should be given tasks commensurate with their training in a manner that does not compromise the local community. Principle 4: Humility and cultural competency are critical components of developing and sustaining a successful short-term experience in global health.

HealthCare

Project Outline

Zimbabwe/Canada Synergistic Health Improvement Initiative

1.0 Executive Summary

1.1 Background

1.2 Objectives

1.3 Mission

1.4 Keys to Success

2.0 Start-up Summary

Start-up Funding

Table: Start-up

2.1 Services

2.2 Management Summary

2.3 Personnel Plan

Table: Personnel

2.4 Financial Plan

3.0 Important Assumptions

Appendix A:

Annotated Bibliography of some articles relevant to

International Medical Volunteering

Appendix B:

Typology of some articles relevant to

International Medical Volunteering

A Non-Profit Organization Dedicated to Helping Those in Need in Zimbabwe