Potential pitfalls

Pitfalls to be avoided include the following:

1. Failure to adapt programs to local needs and priorities. Even within countries, different areas have different and unique needs, and careful planning involving the local medical and political community is a prerequisite to success.

2. Medical tourism. The one- to three-week visit by a well-meaning but unprepared health worker takes valuable time and often resources from hosts who are already overburdened. While it may be a profound experience for the visitor, and interesting for the host, the value in terms of sustained benefit to the population served is usually marginal. Some exceptions might be highly technical teams that perform specialized services not available in-country, and which do not require long-term follow-up care after the service is complete (e.g. cataract removal, cleft palate repair, vaginal fistula repair). Another successful model for short-term (four- to six-week) experiences has been the establishment of a mentored teaching service at a particular foreign hospital (usually involving a formal twinning agreement between the US and foreign hospital), so that the residents and students rotate through (as on other services at the home hospital) and work together with the in-country trainees. The US trainees complete preparatory training prior to arrival, and are able to "hit the ground running" and contribute from the start. Although the training benefits both the US and in-country trainees, true reciprocity (bringing the foreign trainees to US clinical facilities for clinical work) is severely limited by hospital regulations and liability considerations.

3. Failure to train in-country staff. In general, all medical and public health activities should include training and transfer of skills that will empower the in-country staff personnel to carry on and sustain such efforts.

4. Siphoning key personnel from other important programs. The critical scarcity of health personnel in low-resource countries is worsened when well-funded donor country programs siphon doctors, nurses, and medical officers away from other vital activities. The rapid expansion of health services demanded by the attempt to improve and broaden HIV/AIDS care thus threatens to detract from other important high-value programs, such as childhood immunization and maternal/child health programs. Now that more donor funds and programs are being introduced, it is important that an assessment of the absorptive capacity of the training system be made at the outset. In order to expand the numbers of available health personnel quickly, new programs to train community-based workers for specific limited health tasks will need to be developed, in the context of a national health manpower plan.

5. Failure to evaluate and adjust. In the eagerness to respond to a crisis, evaluation is often overlooked. Programs such as an international medical Peace Corps should be front-loaded with operations and health services research to ascertain what works best, and to guide program development. A steering committee needs objective information in making necessary adjustments.

6. Failure to recognize the interconnections of research, training, and services. Research guides and validates the science on which training and services, both preventive and clinical, are based. Conversely, services influence the priorities and concerns that drive the science. Each arm strengthens the other. Scientific method is appropriate to virtually all activities of medicine.

Recognition of the importance of "downstream" applied science to study operations and health services has contributed much to current practices. Ergo, in the planning phase of any major global health endeavor, the components of service, training, and research should each be discussed. 7. Failure to sustain. Programs must have sustainability built into their planning. Resources, both human and financial, must be arranged at the outset for the future continuation of efforts. Unless the infrastructure issues identified in the 2006 World Health Report are addressed and improved, many of the efforts to train health-care workers will not have a sustainable impact on the dire situation that currently exists in many of the most threatened nations.

The challenges are great, but none of the potential pitfalls is unavoidable, and we are cautiously optimistic that many programs will prove valuable in approaching the targets set for the Millennium Development Goals. However, it is imperative that such programs be part of each country's national manpower training program, and be coordinated with the management, education, and planning activities of the national leadership. Without national leadership and sustained commitment, there is little chance of success.

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