International health foundation programmes
Authors: Fred Martineau
Publication date: 20 Jan 2007
Brian Nicholson, Gareth Lewis, and Fred Martineau review opportunities at postgraduate level
Modernising Medical Careers offers a chance to provide structured training programmes addressing clinical and nonclinical knowledge, skills, and attitudes needed to work effectively for a developing country's health service.  We outline and discuss opportunities and developments available for postgraduate international health training in the United Kingdom. We also look at demand and potential benefits for the NHS.
Professor Rod Griffiths, president of the Faculty of Public Health, recognises the benefits of international experience to the UK health system: “Many people come into UK public health having worked overseas and seen the difference public health can make. Posts which enable trainees to gain some of these international insights are to be welcomed.”
Lord Crisp, formerly the chief executive of the NHS, has been asked by the UK government to assess how the UK's experience and expertise can be used to support the developing world in delivering health care to all.  “I have no doubt,” he says, “that benefits of international experience are two way. This is particularly true if placements can become part of a longer term relationship between people or institutions, with regular exchanges, sharing and learning.”
International health education in the UK
The UK has seen a welcome increase in undergraduate opportunities in international health. About 100 students a year graduate from intercalated international health BSc programmes at University College London, Bristol, and Leeds. Other students can develop their interest by doing student selected components (SSCs) in international health or through extracurricular opportunities available with student societies such as Medsin.
Similar opportunities at postgraduate level have been slower to materialise. Only two courses are available within the postgraduate medical system in the UK which cater for this expanding group of UK medical graduates interested in international health. The first is an academic post in international public health, which is part of the University College London academic foundation year 2 (F2) rotation.
UK trained doctors would develop greater competence and confidence to work globally, adding to human resource capacity in developing nations
The second is a four month F2 post in public health as part of a one year rotation at the London School of Hygiene and Tropical Medicine in the North Central London Deanery, which is available to three doctors a year. Negotiations were underway to set up a similar post based at the School of Health and Related Research in Sheffield from August 2007. Unfortunately, this post could not be accommodated into the foundation year programme owing to funding priorities. Dr Karen Lock, from the London School of Hygiene and Tropical Medicine, asserts that “through provision of these individually tailored opportunities to partake in international research projects or health policy initiatives, junior doctors are encouraged to consider a career in the shortage specialty of public health.”
The Alma Mata Global Health Network links over 500 health professionals and students interested in international health, giving information on careers in international health and training. Members are closely involved in lobbying for, and development of, internationally focused training for NHS staff and medical undergraduates. Two recent surveys of Alma Mata members have shown considerable demand among UK medical students and junior doctors for global health training after graduation incorporating career pathways within the NHS. The results of these are summarised below.
Global Health Directions
The first Global Health Directions survey, in Autumn 2005, aimed to explore what ideas Alma Mata members have for their future careers. Figure 1 shows the planned career paths of the 59 doctors and medical students who completed the survey.  Eighty six per cent of respondents planned to work with humanitarian or development agencies in future, with 76% of respondents stating that they planned to follow a UK based career with some periods of overseas work. Seventy one per cent of respondents were interested in specialist training in public health, and 86% agreed they would be more likely to opt for this training if it included a period of overseas training.
Survey and demand
In summer 2006, a second Global Health Directions survey was done to establish whether there is a demand for international health training in the foundation years and in what specialties members felt training would be most useful. Of 115 respondents, 103 would consider an international health foundation programme, while 82 would consider moving deanery to apply. Respondents ranked from zero (not interested at all) to five (top priority) which clinical specialties they would like to see accompany an F2 rotation in international health (fig 2). The five most popular specialties to go with an international health placement are:
Obstetrics and gynaecology
These surveys identify a demand for international health foundation programmes and a potential mix of clinical specialties for these programmes from a trainee's point of view. According to Andrew Furber, consultant in public health in Sheffield, the survey results provided “great evidence to make the case to the local deanery and foundation programme that a post in international public health would attract high quality candidates.”
Many UK doctors wish to work abroad or have already done so.  A formalised training programme in international health would further increase trainees' motivation to do so. The added flexibility of such a programme would allow them to arrive with a more suitable range of clinical experience and a better understanding of international health issues and knowledge of how to address them, while also developing essential nonclinical skills.   UK trained doctors would develop greater competence and confidence to work globally, adding to human resource capacity in developing nations. 
Public health and academic medicine in the UK would also benefit through these means
Ringing the exchanges
Exchange schemes with staff from developing nations have already proved effective in building the skills base of overseas doctors, allowing them to benefit their own health service on return.  Incorporating such schemes with a programme focused on international health issues would increase the feasibility of such an exchange as well as improving the relevance of the experience. Cooperation with the Tropical Health and Education Trust and other non-governmental organisations would be an ideal way to facilitate these exchanges.
The F2 programmes in University College London and the London School of Tropical Medicine and Hygiene/North Central London Deanery show that collaboration between universities and the NHS can develop the capacity and expertise of UK and overseas doctors for work globally in both developed and developing nations. Postgraduate programmes can also be a focus for recruitment by non-governmental organisations to deepen and expand their global health worker capacity.
Benefits to NHS
Training UK doctors in international health brings several benefits to the NHS and has been recognised as an important element to understanding the broader aspects of health.   The General Medical Council recognises the importance of understanding “the wide range of cultural, environmental, and ethical issues that will increasingly impinge on the problems of health” in Tomorrow's doctors.  Most of our surveyed members wanted to end up in the NHS after working abroad, bringing with them the well documented benefits of such a secondment. 10
Ethnic communities often do not have their specific health needs addressed or have difficulty accessing health care to the same standard as others. A more culturally aware doctor returning from work overseas is better suited, and arguably more likely, to provide effective health care and to identify with problems experienced by those traditionally underserved. 10 Public health and academic medicine in the UK would also benefit through these means.
The potential advantage of overseas work to medical practice in the UK has already been established by most royal colleges, who allow work abroad to contribute towards UK basic specialist and higher specialist exams. These schemes need to be consolidated and expanded.
There is demand and capability for the UK to expand postgraduate programmes in international health. This would help the UK to fulfil its commitment to improving health systems of developing nations.
However, the recent rejection of the bid by the School of Health and Related Research in Sheffield shows how deaneries and foundation schools continue to be inflexible with funding. To make the most of this potential, future postgraduate opportunities must be tailored and created to the needs of developing countries' health systems, collaborating nongovernmental organisations, and the priorities of interested trainees.
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- BMA Health Policy and Economic Research Unit. BMA cohort study of 1995 UK medical graduates . London: BMA: 2005: 8-10.
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Fred Martineau foundation house officer 2 Bristol Royal Infirmary