1. To prepare residents who will likely go on short-term medical missions abroad either during or after residency
2. To provide residents with a basic understanding of global health principles and trends
3. To expose residents to career paths that include global health work

The course was seminar-style for a small group of residents. The list of topics included:

1. Broad topics – Introduction to global health, vaccine-preventable diseases, health systems, health workforce
2. Clinical topics – HIV, malaria, parasites, NTDs, malnutrition, chronic diseases, minor trauma, adolescent health and a lab session where we looked at tropical diseases, practiced preparing and reading basic gram and acid-fast stains
3. Specific perspectives – Health systems after a crisis, using a limited formulary, the ethics of short term medical missions
4. Spotlight on specific countries – Honduras, Dominican Republic, Haiti and many examples from Ethiopia woven in to the talks.

The one-week intensive course has gone very well. An opportunity for residents to become familiar with common terms used in global health (like MMR, Infant mortality, DALYs, MDGs) and to start to compare countries using values for each of these. The course offered residents an opportunity to meet a number of experts from different fields. We deliberately started each session with a discussion about the speaker’s career path so that residents could get a sense of how careers often evolve into global health. The more clinical discussions were also very well-received. An opportunity for residents to review what they rarely see and to practice skills that have become out-sourced in our system (such as gram staining) but would likely be expected of a doctor practicing in a more resource-limited environment.

All in all, a very successful week. We will certainly run the course again next year and consider expanding it to take more residents and include more topics. As medical missions and global health become more popular, more residency programs will likely be inspired to offer these kinds of experiences for interested residents.

The challenge lies in developing an e-learning strategy that responds to local needs. In the US, the driving force to use technology is to improve the quality of the education. We use it to improve communication skills, physical exam skills and have more opportunities to practice cases. These uses appropriately respond to recognized deficits in our students.

Medical education in Africa has different challenges. According to the Sub-Saharan African Medical School Study, the biggest challenges are lack of faculty and inadequate infrastructure. Now that more countries in Africa are scaling up training of health workers, including physicians, it is critical to address the bottlenecks. So here I suggest there should be 3 explicit goals of e-learning programs in Africa, and I list them in order of priority:

1. Reducing the need for faculty time: Despite inadequate faculty, medical schools in Africa are increasing enrollment. They need to figure out how to teach more students with limited faculty. Technology should be used to meet this need. Self-study curricula (like what the Khan Academy has done for K-12 would be great). Medical schools should select courses to pilot e-learning based on their faculty needs – if there are not enough anatomists, then the anatomy course should be prioritized for integrating e-learning. As schools are testing e-learning in their curricula, one explicit indicator that should be measured is faculty-time required. If it takes faculty more time to upload their curricula, engage in on-line discussions and evaluate – is it really meeting the acute needs?

2. Cost-effectiveness: It takes money to provide educational supplies, classrooms, housing and supervision for the growing number of medical students in Africa. As the enrollment increases, schools will be looking for ways to make their dollars stretch. If we can use technology to provide online access to resources (instead of buying textbooks), give laptops to students so they can study more often at home, reduce the number of faculty it takes to run a school – we most certainly will find cost-savings. To prove this, schools that are pioneering the use of technology must include cost-analysis in their evaluation.

3. Quality – This tends to be the most obvious reason to use technology and is often the driving force, but I put this deliberately third because it is sometimes over-stated. Sure you can use technology to connect a school in Uganda with a US school to watch a lecture on HIV, and sure it will give yet another perspective on a condition commonly seen. But is that really meeting the acute and critical needs of the system? The use of technology to improve the quality of training in Africa should be competency and need-based. By first being explicit about the skills all graduates need, evaluating their competency, and then using technology to provide additional teaching where gaps exist.

Developing an e-learning strategy that prioritizes the reduction of faculty time and cost are increasingly important as technology becomes a more common tool in African medical schools.

There’s another brain drain that doesn’t seem to get as much attention – the internal brain drain. Of those medical graduates who chose to stay in-country after training, many don’t go on to clinical practice – they get lured into non-clinical jobs by governments or local NGO’s. Foreign NGO’s pay better and offer better benefits. I remember when I was in a hospital in Tanzania a few years ago talking to the one internist working there – he complained that so many of the residents he trained would go off to do a Masters in Public Health because then they could get a job with the Clinton Foundation – have a good salary and still feel like they were improving the health of their country.

The Sub-Saharan African Medical School Study examined the plight of faculty in medical schools. These faculty often see patients in public hospitals along side their teaching responsibilities. This study found that in a 5-year span, 25% of faculty were lost to internal brain drain (either working for the government or NGOs).

Ironically, when I’ve talked to physicians in Africa who have moved from clinical to policy or public health work, they miss their patients. In fact, in a recent trip to Ethiopia some of these docs say they would be happy to see patients on a part-time basis or in the University clinic with residents but their jobs would not allow them that option.

There are two questions that need to be addressed:

- What are the real numbers of this internal brain-drain? A brief look at physician tracking systems in Africa reveals that these numbers are likely not being captured. We need tracking systems that gather this data and we need more research done to understand the breadth and scope of this problem.

- What can NGOs do to address this issue? Can they allow or even require their physician on staff to do some amount of clinical work? Can they partner with governments or Universities to allow their employees to work in public clinics or medical schools? If NGO’s made this a policy, it could apply to all doctors working in the country – not just the African-trained doctors. Imagine if all doctors who come to Kenya for research or policy work were required to spend even one day a month in a clinic – access to specialists would certainly improve! 

Both quantifying the internal brain drain and finding innovative ways to address it must be on the table if we are to scale up the physician workforce in Africa.

• In Tanzania, D-Tree with Harvard faculty tested eIMCI with significant impact on the sickest kids because full guidelines were followed. Interestingly, patients felt they were getting better care (with use of PDA vs. paper) because clinical officers were referring to a phone/guidlines.
• MoTeCH in Ghana provides pregnancy information for women and their families using $40 phones, and using an open source software Open MRS for their platform. Interestingly, most families preferred getting their information using voicemail rather than text messages (due to literacy rates)
• Operation Asha in India uses fingerprints/biometrics to track TB treatment, sending an SMS if missed doses. Good results and the cost is $3/patient.
• Wired Mothers Project in Zanzibar  reported a 4 fold increase in skilled birth attendants present at birth when mobile phones connect midwives.
• In India, lactation consultants providing cell-phone consultations resulted in increased rates of exclusively breast fed infants

With African having 60% penetration of mobile phones (and growing…) and South Africa with 20% penetration of smart phones (compared to 50% in the US) there is certainly a lot of potential for real impact using mhealth.

1. There are many, many pilots in mhealth – globally. What’s needed now is a focus on interoperability, scalability and sustainability.

2. Financing is a challenge – there was little talk about how physicians will get reimbursed for services related to mhealth. Incentivizing physicians is going to be a challenge.

3. Multiple stakeholders – clearly there is a need for inter-sectorial collaboration to make mhealth scalable, and successful. The government needs to provide oversight and the private sector needs to drive the innovation. There were many examples of successful private-public initiatives from around the world. The Switchboard partnership with Vodafone in Ghana is my favorite.

4. Data, data, data – with home monitoring and 24-7 data being created, there is going to be a need to analyze this data, and present it both to the patient and the physician in a meaningful way that drives appropriate treatment.

5. Training – there was really not much talk about this, but I think it’s critical that we start thinking about training physicians in technology and change management. This next decade will see radical transformations in medicine by technology, yet medical school curricula and their developers are not even thinking about providing in ehealth. While it may be difficult to train on specific technologies because the winners are not yet clear, we should certainly be thinking about training doctors in change management. Our next generation of doctors should be able to adapt to a rapidly evolving environment when they graduate.

I’m very energized by the conference and definitely hope to return next year. I will be writing about specific highlights in the days to come.

That said, I heard at the mHealth Summit in Washington DC this week an innovative public-private initiative that has created a tracking system in Ghana, as an indirect benefit of a business venture. Vodafone (who only has 18%) of the market share in Ghana, teamed up with the Switchboard (a US company) and the Ghana medical association. They gave each of the 2200 doctors in the country (public and private) a sim card with which all the doctors could talk freely to each other. They were already spending minutes and money consulting each other – now these minutes were free. All the rest of their calls to non-physicians are charged. Vodafone got 100% of the physician market, making 1.3M in the process and the doctors got free calling to one another. When they distributed the SIM card, they collected names, specialty and place of practice – so now the MOH even has a tracking system to know where all their doctors are. They are now expanding to Tanzania.

That is mHealth at it’s best – innovative, scalable and sustainable. I like it.

And as I understand it, to create open access material you need to have your material licensed so that it can be shared, reused etc…I haven’t done it myself but expect that it does take some time to deliberately prepare your material to share. Enough time and effort that this is one of the primary services offered by OER.

So the challenge, in my opinion, is how do you incentivize resource-strapped medical schools in Africa to go through this process and make their material open access? I don’t doubt their intentions,  but why should they spend the time it takes to obtain the licenses and make their material ready for open access when they have more pressing challenges on their minds? There may be exceptions such as Stellenbosch University, who already have elearning material ready to share and do so, but most schools are still trying to develop content for their elearning programs.

This might be an opportunity for a grant, a competition or for partner schools in developed countries to take on as their social mission. Given the shortage of doctors, the shortage of faculty and the fast pace of new medical schools in Africa, increasing open access material and establishing a definitive destination could make a huge contribution to the field.

The question is – how do you get this done?

The brain drain of physicians trained in Africa to the US, Canada and other developed nations is an on-going challenge. In Ethiopia, a country of over 80 million people, there are only 3000 physicians. To address this challenge, the country plans to scale up in large scale the number of medical schools and therefore physicians trained in the country. In essence, they plan to flood and retain. At public medical schools (which are the majority), medical education is free, then graduates are expected to complete compulsory service of 2-4 years in country. After that, physicians are free to go wherever they want. Many go to western countries to complete residency training, others go to NGOs in-country and others go in to private practice – all options that pay more than public service where then need is most acute.

So if Ethiopia is investing in to provide medical education to thousands of students each year, only to supply richer countries where access is not nearly in as much a crisis, shouldn’t we pay for their service?

Medical education for a US student costs around 250K – now granted a good portion is paid by students but States often subsidize higher education, so shouldn’t we pay back some of Ethiopia’s investment, especially given the huge deficit it leaves behind?

The issue of retaining doctors should clearly be addressed by the Ethiopian Ministries of Health, Education and the medical schools but perhaps it’s time the West takes some responsibility for the brain drain?