Acting locally, impacting globally

Irish doctors have a long history of working in the developing world. A new initiative seeks to co-ordinate the Irish health service’s work in the area. David Lynch reports

There is a long tradition of Irish doctors and other healthcare professionals working in developing countries around the world.  Building on that history, last year the Forum of Irish Postgraduate Medical Training Bodies established a global health strategic working group. The group brings all the medical training bodies together with a “shared vision and ambition to improve healthcare and health education globally”.

This group has begun an initiative called ‘Global Health Education Ireland’, which was launched last month at a well-attended symposium in the College of Anaesthesiologists of Ireland in Dublin.

The symposium heard from a wide range of Irish doctors and healthcare workers who had experiences working in low- and middle-income countries in Africa and Asia (see panel). Concerns were raised by some attendees over the lack of education in global health matters within the current medical curriculum in training bodies, while others said there should be more supports introduced by the HSE to help facilitate doctors who want to work in the developing world.  

Addressing the conference, Dr David Weakliam, the lead for the HSE Global Health Programme and the chair of the forum’s group, provided the global and local context. He cited the recent universal health coverage declaration by the United Nations General Assembly and global challenges in terms of shortages in trained medical staff. 

“When you talk about universal health coverage, you have to talk about health workers. There is no healthcare without health workers,” Dr Weakliam told attendees at the symposium.

“This is at the heart of the problem, that there is this shortage across the board for the health workforce.”

The symposium heard that there was a global shortfall of 18 million health workers.

“We need to match supply to the need. We need to train healthcare workers. But the reality is, there is a deficit,” said Dr Weakliam.

“The reality is that in the poorer countries, there often isn’t an economic demand to employ the workers. There is a supply problem, but also a demand problem.

“But it doesn’t end there. In the higher-income countries, we find that there is a greater supply of health professional than our needs, if you go by the WHO threshold. But we have demand [for health services] even greater than that.

“We have a high demand for healthcare, we have a shortage of healthcare professionals in Ireland, as many higher-income countries do. That draws on [doctors from] poorer countries, and that is the challenge of migration.”

Challenges

Dr Weakliam also noted Ireland’s obligations under the WHO Global Code on the International Recruitment of Health Personnel. The code says that countries such as Ireland should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers. This has been highlighted in recent years by some of the local representative bodies. For example, in its submission on the Framework for Workforce Planning in July 2017, the IMO noted that this country’s “inability to achieve medical workforce sustainability from its own graduates renders it incompliant with the WHO Global Code on the International Recruitment of Health Personnel”.

In his address, Dr Weakliam also praised the work done by various stakeholders in Irish health in the developing world, and noted that ‘Global Health Education Ireland’ would be an opportunity to bring this experience together.

“The value of just having this network of us all working more together, to meet, to learn together, to be a place where we can come together and empower individual initiatives, but also be more collective,” Dr Weakliam told delegates.

Speaking to the Medical Independent (MI) at the symposium, Dr Weakliam admitted that there are challenges when it comes to recruitment of healthcare workers, both in Ireland and abroad. 

“I think you have to see that today, the health workforce globally is very mobile,” he told MI. 

“Health professionals move easily between countries. So it’s inevitable that there will be doctors in other countries coming to work in Ireland, and it is inevitable that Irish doctors and medical professionals will work away. So the challenges for us is to realise the best for our own health service is that, — and this is in line with the WHO Code of Practice — that we would seek first to do our best to train and retain the workforce that we need.

“Inevitably, as is the case with other countries, there will be situations that we need to recruit internationally and then it is about how we do that in an ethical and appropriate way, and our response to that within the HSE has been to set up a programme currently with doctors from Pakistan and Sudan [The International Medical Graduate Training Initiative (IMGTI)], whereby they come to Ireland to work for two years, in training posts.

“After which, they then return to their own country, so they benefit from the training [in Ireland] and their own countries benefit because they go back.

“So it’s of interest in those countries and it’s also to the benefit of us, because they fill some of the gaps. But it is in a very structured way, because it means that they are getting very high-quality training, but also, we benefit from high-quality doctors coming from those countries. But the ideal is that we have sufficient [numbers of doctors] of our own.”

There are 158 doctors working in Ireland under the IMGTI , according to figures supplied by the HSE to MI.

Asked whether there is much impact that bodies like the HSE can have when migration forces are so strong, Dr Weakliam said “well, it’s always going to be challenging, because of that mobility, and health professionals sometimes see benefits in going to work in other countries, that they may choose to do that.

“Mobility works in both ways, but the challenge for us in Ireland is to create an environment for our professionals to stay, so that is part of our challenge that we train enough professionals to meet our needs, but then when we train them that we are in a position to keep them. There will also be a challenge for what is a global market for doctors and health professionals.”

HSE

Also addressing the symposium was HSE CEO Mr Paul Reid, who spoke of his experience in the developing world in his former position with Trócaire. He also mentioned that when he worked for Fingal County Council, over 20 per cent of residents were born outside Ireland, so global health issues were also faced at home.

 “I got a good experience of the Irish health commitment to overseas development [when he worked with Trócaire] ,” Mr Reid told delegates.

“You cannot come into this role [as HSE CEO] and think of it in an insular way; we have to think about it from a global health perspective.

“It is about looking globally. We can’t address issues like antimicrobial diseases and others [on our own]. It is about what we can do in an international health environment. The HSE has a very proud tradition.

“What I have been impressed by with our programmes I have seen to date is the focus on capacity-building, because my experience is that it is not just about going in and making short-term interventions, it is about how you build capacity from a programme and make it sustainable. And some of the programmes that are in-train at the moment will lead to long-term sustainable capacity.”

Mr Reid mentioned work undertaken by the HSE in Mozambique with quality training initiatives in 14 hospitals and training in 12 hospitals in Ethiopia. He added that there were further training programmes of doctors in Zambia and Sudan.

During his address, Mr Reid also placed the current recruitment and retention crisis with Irish consultants into its global perspective.

“There are also significant benefits for ourselves when we engage overseas,” he said. 

“We have a very significant global challenge in terms of recruitment of medics and the recruitment of consultants; it’s not just an Irish problem.

“It is a very difficult problem, not just for ourselves. We have to find the right balance between recruiting consultants, sometimes from developing countries, countries we are trying to help develop themselves.

“So it is a very difficult balance for ourselves.”

When MI asked Mr Reid whether he believed we have reached the “right balance”, he said “the point I was making in the presentation is that you always have to find that balance between trying to support capacity and development of doctors [in developing countries]  and, at the same time, attracting some of those doctors and consultants to our own system.”

In terms of the recruitment and retention of Irish consultants and a reliance on doctors from abroad, Mr Reid said: “The fact is, we need to recruit more consultants and I want us to recruit more consultants. It’s a global problem for all health systems. We are in the process of recruiting. We have recruited 135 consultants over the last year, as well as another 78 coming through the pipeline at the moment who will be appointed.

“So we are having some success, but it is very difficult.”

Mr Reid added that he is on the record that pay parity for all consultants is an issue in terms of recruitment.

Local initiative, global focus

Doctor trainees overwhelmingly experience positive impacts on their lives and careers from working in developing countries.

That is according to findings from a survey of trainees who had worked in global health, presented at the symposium by Dr Ellen Crushell, the Dean of the Faculty of Paediatrics at the RCPI. However, the survey also highlighted some challenges.

This survey feedback was backed-up the experience of Dr Laura Harvey, Specialist Registrar in Public Health Medicine with the HSE, who spoke at the symposium about her experience of working in South Sudan and Ethiopia.

“I gained a lot from my experiences… working in a different health system gives you a different perspective on our own health system… I think global health work should be encouraged by the HSE and the RCPI,” said Dr Harvey.

However, she also outlined her concerns over the impact on doctors’ pension schemes that taking time out to work in developing countries can have.

“A lot already been done. Some of the faculties now recognise global health work as part of your training…[the] HSE facilitates career breaks,” she said.

“But I suppose for people like me who take time out, there is a little bit of a gap. When I left, I was not allowed to pay into my pension when I was away and I lost some of my benefits by leaving. I felt quite annoyed at the time; I did not feel I was going to come back to the HSE, but here I am. I thought they would be encouraging me to come back, recognising that I would be bringing back new skills and perspectives.

“But instead I felt they [the HSE] were saying ‘do whatever’. The pension scheme is something I think we need to look at particularly.”

Speaking about working in Africa, Dr Harvey said it was important to be prepared before you go. To examine your motivations, “why are you going and what are you going to achieve?”

She added that “unconscious bias is something you are going to have to consider as well”.

“We all have our own biases and it is important to be aware of them before we go out.”

Prof Diarmuid O’Donovan, Professor of Global Health at Queen’s University Belfast, welcomed the Global Health Education Ireland initiative.

He told attendees: “We need to link people, to develop new relationships and partnerships, we need more learning and collaboration and we need to work on how to do that better, both here and everywhere else.”

Concerns were raised by a number of speakers at the symposium about the relative lack of global health education in the medical colleges. In his address, Prof O’Donovan outlined the myriad of ethical, social, cultural and political challenges that arise in global health and health-based interventions in the global south.

In response to one doctor in the questions and answers session who referred to the lack of education in global health for doctors, Prof O’Donovan said: “I think it’s absolutely core for all health professionals… I think it should be something that is included; it should not be something just skirted about.”

“We should be also talking about reciprocity; it should not just be one-way. We should be looking at ways to enable exchanges [between health systems in the developed and developing world].”

Some speakers at the symposium also highlighted the need for consultants to be facilitated if they want to take time out from their career to work in global health.

Prof Pankaj Jani, President, College of Surgeons for East, Central and Southern Africa (COSECSA), outlined the work of COSECSA in Africa, noting that its “focus is on rural surgeons, because it is the rural population which is suffering”. He said that the work being done “is something that can touch mankind”. Prof Anne Matthews from the Dublin City University School of Nursing and Chair of the Irish Forum for Global Health outlined the work of Irish nurses and midwives globally, while Ms Katie Sheehan, Assistant Director of Nursing in University of Limerick (UL) Hospital, gave the example of the training programme conducted by the UL in Ghana.

Dr Martin Rouse spoke about work that the ICGP undertakes in Malawi and Dr Brian Kinirons, President of the College of Anaesthesiologists of Ireland, highlighted the work the College has done in Africa in recent years.