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“The roaming doctors” – or what are we waiting for? A plea for interactive cooperation in health

By on December 1, 2018

Elies van Belle is a medical & public health doctor. She has been working for 9 years in different health projects in Africa, with NGOs and with the bilateral cooperation. She currently works in Brussels with the Belgian medical NGO Memisa.

I feel compelled to react on the recent  blog  by Willem Van De Put and Werners Soors (“The ITM symposium on 40 years PHC: is there a doctor in the house?”) , in which they gave their take on the ITM symposium on 40 years Primary Healthcare (October 23rd ), and more specifically to their statements regarding the last panel discussion. ( I will not focus here on their broader point on the overemphasis on medical doctors in the PHC debate.)

Although I perhaps didn’t make myself clear enough at this closing plenary, I feel that my words were distorted in an argument which I would label rather “populist” (even if that was probably not their aim).  Anyway, hinting that my world view would approach “the promotion of  ‘white doctors’ roaming the world as ancient imperialists who think their culture is superior” demands a strong rebuttal from my side. I refuse to be cornered as some sort of nostalgic health ‘imperialist’ just because I criticize certain situations and propose aspects of action that are then cheaply interpreted as top-down, classical and naïve North-South development aid. Maybe I wasn’t clear enough on the 23rd but I would like to use this opportunity to put things right and also provide some of the broader perspective of my argument.

So here I go.

With all due respect, Werner, Willem, would you have used the same arguments and have had the same legitimacy to use them, if you hadn’t had the opportunity to work and live and be exposed to different health systems for a long period – an opportunity that most of your younger colleagues are now deprived of?

I will be talking for the health sector, but I think my statements might apply to all other development sectors as well.

What is the problem? The ‘North-South cooperation’ over the past decades exposed medical doctors and other ‘white’ health professionals of the North to health care systems in less fortunate countries, which allowed them to build expertise based on local experience. This exposure, which was often a combination of  health services organization and clinical work, is necessary if we believe that exchange and discussion are key for mutual understanding, learning from each other, and eventually change. It also provided these people with a legitimate place at the development discussion table. The risk was, however, real that these exchanges felt as top-down, even if they were not necessarily intended this way.

Over time, as the number of doctors in developing countries increased, clinical work by foreign doctors was labelled more and more as “substitution”, meaning that foreign doctors were taking the places of national ones and that there couldn’t be an added value in doing so. And so, development aid in the health sector took more and more distance from clinical work and focused on public health, health service organization or disease control initiatives through vertical programs. Many of these foreign doctors, while still engaged in developmental work, ended up being more and more disconnected from the hands-on situation and therefore alienated from the reality in the field. At the very least, the risk of “ivory-tower opinions” increased.

Development aid is currently shifting from North-South “transfers” (whether it is money or knowledge) to global exchange, partnerships and networks, in which terms like North and South become increasingly meaningless. Perhaps this trend is not going fast enough, but it’s certainly the right one. Nations profit from the exchange between individuals, who often grew up in completely different cultures and circumstances. This makes mutual understanding perhaps less evident but also much richer in the end. Still, this exchange is not really structured or deliberately developed and is suffering from taboos like ‘medical doctors from the North should not substitute the ones from the South’.

For people to exchange and learn from each other, they need to know each other and they need to know the ‘other’s’ system within the complex local reality to prevent blind criticism. The ideal learning situation for an adult is to be exposed to a completely different system in order to understand the relativity of one’s own.

Although the context of “circular migration” is certainly different, it can perhaps provide some inspiration in this debate.  Circular migration is a form of migration that allows migrants (let’s say in this case, health staff) some degree of mobility back and forth between two countries, but it also brings the added value of being exposed to a different health system. Although the focus is on employment and regulation of migration & brain drain in this case,  one could also consider perhaps North-South-North or some sort of  ‘reverse circular migration’, which would then be conceived as a learning opportunity for young health staff from Northern countries?  After all, the experience acquired in the South in recent decades has inspired many of the health professionals in the North to be agents of change back in their own country.

So here is my statement:

Current expertise and knowledge in development cooperation in “the North” are rightly based on years of experience of working in both the North and “the South”, creating both legitimacy and competence to engage in the dialogue on development cooperation in health. 10-15 years from now, this critical cohort of public health experts will, however, have retired, and they will not be replaced, as the present paradigm on development cooperation considers ‘hands-on’ working in a fragile or “underdeveloped” health care system as ‘substitution’, and this supposedly in line with the Paris Declaration and the Busan partnership on Aid Effectiveness. As a result, the international dialogue on global health will stop – or perhaps more accurately (and worse), will be based merely on theoretical analysis, constructions and deductions.

Policy and political dialogue will depend on administrative and power relations, based on increasingly unfounded opinions and global visions without much of a backup from technical evidence-based arguments because those around the table will never really have been exposed to the local system under consideration.

How can we expect young health professionals who are nowadays catapulted into administrative, often high level positions (without getting the opportunity anymore to learn from experience, gain technical expertise and learn from their mistakes), to be competent and legitimate actors in the future international policy dialogue on global health?

Arguably, health professionals from the North can still gain some experience by working with humanitarian organizations, who send doctors, nurses and midwives to crisis situations for 3 to 6 months, to try to organize emergency healthcare when the system is down, and they obviously do amazing work. But let’s be clear, this is not at all the ideal situation for getting to know, understand and respect a foreign health system from within.

There are also some initiatives to engage young professionals into development cooperation, like the Enabel junior program, which offers the possibility to get a first experience in the field by working for 1 or 2 years in one of the Belgian partner countries. These initiatives are remarkable and commendable, but as hands-on working is not ‘acceptable’ anymore in development cooperation, these young professionals are often not practicing their profession, but “assisting” the local management, and young doctors are not attracted by this opportunity.

Meanwhile, universities in the North, who used to “accept” overseas internships in developing countries, are more and more reluctant to do so, as the quality of care is not guaranteed and they fear their students will not receive proper training, or worse, will be exposed to malpractice.

Academic institutions offer scholarships to health professionals coming from the South to study public health in the North. Besides theoretical courses, it is the exposure to foreign health systems, in the case of ITM for example the Belgian one, but also those of fellow students, that allows health professionals to learn the strengths and weaknesses of their own health system. Fortunately, Belgium has many very experienced ‘teachers’ to facilitate these courses, because they have worked in and studied those health systems in the South for years.

We tend to forget that the way today’s Belgian public health experts gained their experience, was by working as health professionals in the local system in the South – the hospital, the health district, the health center, the community, the ministry of health; not for three months, not for a year, but often for many years. This experience gave them the opportunity to appreciate, understand and respect another health system, and, by working alongside local peers, to learn from each other.

Health care workers of the South, besides the happy few who could obtain an international scholarship, never had this opportunity. Learning has indeed been too much the North learning from the South in the past, instead of a real exchange between two (or more) countries. Today’s global trend is (still) not one that allows people from the South to be more exposed to a learning situation in the north (read a completely different health system) – in spite of the example of circular migration I gave above, most health staff from the South leaving for the North do not come back. As a result, international dialogue in health risks to become an exchange between two parties who can’t understand each other, as they’ve never been (long-term) exposed to each other’s systems.

At the same time, there’s a risk that due to the asymmetry of the learning opportunities, the often strong (and warranted) criticism and critical dialogue on the quality of care in many fragile countries will be increasingly interpreted as cultural superiority and arrogance. In fact, this is already the case in some settings. Denouncing the appalling quality of care in some countries by the international community is one thing, the reactionary attitude of local elites who are rather happy that the international dialogue is jeopardized for the abovementioned reasons, is another.

If we accept that access to healthcare is a fundamental human right, then the health workforce is key in realizing this. Investing in a global health workforce means investing in their training and motivation, in order to allow collegiality and peer learning to develop, and learn from each other and understand each other’s differences and similarities. This can only be realized through exposure to health systems worldwide, and starts with professional clinical practice and experience, not with administrative work  (although the latter can be part of gaining relevant experience).

If we really want to talk about global health and global citizenship without just using them as empty buzzwords, we have to focus on the people who deliver the care, or to put it in the words of Roy Remmen during his key note speech at the conference, “if we lose the health care workers, health care stops”.

And so, I am launching a call to develop interactive cooperation in health, to allow all young professionals to get worldwide exposure to health systems, based on exchange and peer learning starting with ‘simple’ clinical experience. This is not to be confounded with substitution or lack of respect for ownership or local responsibility. It is, instead, based on acceptance of each other’s differences and on the belief that we can learn (a lot) from being challenged when exposed to a system which is not our own.

Interactive cooperation could be defined as mutual exposure to each other’s health system in order to learn (jointly) about one’s own s system through the appreciation of the strengths and weaknesses of the other. Such cooperation should on the one hand deal with the current asymmetric position in development aid, but also with the fact that a real dialogue and mutual criticism can only be based on genuine previous learning opportunities.

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One Response to ““The roaming doctors” – or what are we waiting for? A plea for interactive cooperation in health”

  1. Willem van de Put & Werner Soors

    Dear Elies,
    Thank you for your reaction on our blog. We definitely support your call for interactive cooperation to improve the development of a global health workforce. The many challenges in global health indeed require new ideas on sourcing skills transnationally, and include issues of equity, migration and social perspectives of health workers from all countries.
    So, we are on the same side, and we believe our arguments are valid, regardless of opportunities to work and live abroad, regardless of having clinical experience or not: the legitimacy of our arguments comes from the arguments themselves.
    The first and foremost point we wanted to make in our blog was on the importance of equity, a sine qua non to achieve a lasting effect in building a rights-based distribution of experience and skills. We used the term ‘white privilege’ to stress the point that there are sensitive and political dimensions to the issue, as is shown in the studies brought forward by Remco van de Pas, and as will be discussed December 9th in a side event of the Marrakesh’ migration week.
    You rightly speak of younger colleagues deprived of opportunities to gain international experience. We assume that we can agree that this is relevant for all young health professionals. The central issue of equity is perhaps best illustrated if we compare the reasons that keep health professionals here from applying to non-subsidized jobs in L&MIC with the reasons that keep their colleagues from those countries to do the same here. Only a truly global health workforce can overcome this. Let us join hands to build it.
    A second point is one of effectiveness and efficiency, where even a global health workforce will fall short, if on its own. We all recognize that quality health services are needed to reach health for all, and that a service organisation based on primary care is the most effective, efficient and equitable way to deliver them, in low-, middle- and high-income countries alike. Still, too many of us fail to recognize that quality service delivery is a necessary yet insufficient condition for health. Health for all requires a giant step beyond, and one we failed to take for decades: multisectoral collaboration. We’re talking here about the part of the first paragraph of the Alma-Ata declaration we use to skip: the realization of health “requires the action of many other social and economic sectors in addition to the health sector”. Multisectoral collaboration – as Shyama Kuruvilla and colleagues point out in this week’s BMJ – seeks “to disrupt the status quo positively by instituting business not as usual”. Alma-Ata asked for it. The SDGs ask for it. But it is not an easy task, and only becomes possible (let’s put it bluntly) if we strip off our ‘white coat privilege’ and join hands with all other actors influencing health.
    Warm regards,
    Willem & Werner
    8 December 2018

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