Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA–LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC–NA partnerships can contribute to reductions of child mortality and morbidity globally.

The mission of departments of pediatrics is to improve child health through education, clinical practice, research, and, increasingly, advocacy. This mission is also broadening to include improving health for all children as departments respond to growing calls, both domestic and international, for health equity.1,2 

There have been improvements globally in indicators of health equity, defined as the absence of avoidable or remediable differences in health among groups of people defined by different levels of social advantage related to wealth, power, or prestige over the past 2 decades.3 However, global disparities in access to health services and interventions and health outcomes remain. In 2015, low- and middle-income countries (LMICs) spent, on average, 6.5% of their gross domestic product on health compared with 12% of gross domestic product for high-income countries (HICs).4 There is an additional inequitable global distribution of physicians, with 8.8 physicians per 10 000 population on average in LMICs compared with 28.7 in HICs reported in 2013.5 Although the mortality rate for those <5 years old has improved dramatically in LMICs over the past 2 decades, a large difference between LMICs (47 per 1000 persons in 2013) and HICs (7 per 1000 persons) persists.6 Similar disparities exist within HICs, with, for example, infant mortality rates in the United States varying by state, race, and ethnicity.7 

To address health disparities, improve child health, and achieve health equity, North American (NA) departments of pediatrics have a role in global health (GH), which has been defined as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.”8 In collaboration with LMIC partners, NA departments of pediatrics can contribute to achieving health equity and improving child health by training future pediatricians to provide health care to children from around the world, engaging in clinical care collaborations that can help address health system gaps in resource-constrained settings,9 and conducting collaborative research that has the potential to reduce childhood morbidity and mortality globally.10,11 

Our purpose with this review is to (1) describe the range of current roles of NA departments of pediatrics in global child health (GCH) education, clinical practice, and research; (2) summarize recommendations from the literature for best practices in engaging in GCH in each area; (3) describe challenges departments may experience in engaging in GCH and examples of how departments have addressed these challenges; and (4) suggest next steps for the development of departments’ of pediatrics role in GCH.

The authors are members of the American Board of Pediatrics Global Health Task Force Academics Working Group and are GCH educators, clinicians, and researchers working in LMICs and North America. We conducted a literature review through PubMed and Google Scholar for articles related to NA departments of pediatrics and GCH education, clinical practice, and research. See Supplemental Table 4 for the specific search terms used. The resulting articles were then assessed for relevance to the manuscript. A subset of authors with expertise in each area (education, clinical practice, research) reviewed the relevant articles and, acknowledging that no set of search terms or search engines would definitively unearth all relevant articles of interest for this broad topic, included additional articles from their areas of expertise.

The best practices (Fig 1), challenges, and recommendations for NA departments of pediatrics engaging in GCH included in this review were then drawn from the literature obtained through the search described above and informed by the authors’ experiences as well as input from colleagues in the GCH community. Examples in each area were then selected from the same literature search by using the following criteria: examples were published in peer-reviewed journals, were developed and evaluated by multi-institutional collaborations or were initiatives of pediatric organizations, and demonstrated high-quality outcomes. In the few instances in which published examples were sparse, unpublished examples known to the authors in their areas of expertise were included. The included examples are meant to be demonstrative and not intended to be comprehensive because numerous outstanding GCH programs exist.

FIGURE 1

Best practices for engaging in GCH education, clinical practice, and research.

FIGURE 1

Best practices for engaging in GCH education, clinical practice, and research.

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In this review, we focus on NA departments of pediatrics, but the best practices and challenges are likely broadly applicable to departments of pediatrics within HICs. Best practices and ethics for individual NA-based faculty members caring for specific clinical conditions or conducting specific disease-based research studies in LMICs are beyond the scope of this review and are discussed elsewhere.12,14 

Before describing the possible roles of NA departments of pediatrics within GCH (Fig 2), it is important to clarify that any role must be done in collaboration with LMIC partners because the vast majority of work in GCH is undertaken by staff and faculty at LMIC institutions. NA departments’ of pediatrics efforts should be guided by a key principle of GCH: that the work be done through bilateral, mutually beneficial, ethical collaborations with LMIC institutions.15,17 Any work performed within LMICs should be done with a clear understanding that NA partners are guests in the country, the LMIC partner has experience and expertise in local GCH issues the NA partner lacks, and their work together starts with an assessment by both partners of how mutual and complementary expertise may be best used to develop educational, clinical, or research programs designed to improve child health.15,17 The collaborative work of GCH should further be guided by the principle of cultural humility in which partners reflect on their own assumptions, biases, and values, with a focus on learning rather than knowing.15,18 Approaching collaborations with cultural humility can reduce power imbalances and promote mutual respect and understanding.15,18 

FIGURE 2

Collaborative role of NA departments of pediatrics in GCH education, clinical practice, research, and advocacy.

FIGURE 2

Collaborative role of NA departments of pediatrics in GCH education, clinical practice, research, and advocacy.

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GCH education in pediatric residency training has expanded over the past 2 decades. The earliest published survey regarding GCH training in the United States in 1995 revealed that 25.5% of responding residency programs offered GCH electives or informal GCH experiences.19 The most recently published survey of US pediatric residency programs in 2014 revealed that 58% of responding programs offered GCH international electives, with increasingly robust GCH training including more GCH curricular components (eg, electives, GCH lectures, etc).20 The survey further revealed that 66% have a GCH faculty lead, and 25% offer GCH tracks, which provide formalized, longitudinal training for a defined group of residents.19 There are many examples of well-described guidelines for GCH core curricula,21,24 GCH residency tracks,25,27 and GCH electives.16,19,28,30Supplemental Table 5 provides several illustrative examples as well as guidelines for and brief descriptions of GCH curricula, tracks, and electives.

In addition to providing training and mentorship to residents with specific career interests in GCH, GCH education is increasingly embedded in general pediatric residency curricula. Pediatric residency programs are increasingly providing some GCH curriculum to all residents on topics such as the global burden of disease, use of interpreters, and cultural humility21,25 so that trainees are competent when they graduate to provide care for increasing numbers of refugee and immigrant children in the United States as well as children suffering from emerging infections such as the Zika virus,31 travel-related diseases such as malaria,32 and local outbreaks from imported infections such as measles.33 

Finally, NA departments of pediatrics can play a role in contributing to the education of LMIC pediatric trainees when invited and in collaboration with LMIC partners. This role ranges from informal teaching by visiting faculty to more formalized educational initiatives, such as training in pediatric subspecialties,34,39 joint development of core curricula,22,40,42 short clinical skills training courses (eg, neonatal resuscitation),43,44 and telehealth collaborations.45,48 New and developing LMIC residency programs have been supported through academic partnerships with NA departments of pediatrics, in which guest faculty with experience in medical education contribute to the development of the program.40,42,49 In Supplemental Table 5, we provide several illustrative examples and brief descriptions of GCH education partnerships.

We indicate in our literature review a growing consensus in the best practices for GCH education. These include the following: (1) adequate preparation and orientation of residents before departure on GCH electives16,19,50,56; (2) adequate supervision of residents on GCH electives16,19,57; (3) provision of post-GCH elective debriefing58,60; (4) establishment of ethical partnerships with host institutions, communities, and organizations that support the GCH electives and other educational opportunities, characterized by shared planning,50,61,62 bidirectionality,34,35,50,51,57,62,64 long-term relationships,16,50,51,65 cultural and contextual awareness,50,56,65 and equitable resource allocation8,66,67; (5) contributing to local professional development22,27; and (6) ongoing evaluation.16,50,51 In addition, the Federation of Pediatric Organizations recommended in 2008 that US pediatric residency programs offer core curriculum in GCH for all residents.68 In Table 1, we provide a summary of specific recommendations from the literature for each best practice.

TABLE 1

Best Practices and Recommendations From the Literature for Engaging in GCH Education

Best PracticeSpecific Recommendations From the Literature
Adequate preparation and orientation of residents before departure on a GCH elective Careful selection and preparation of trainees for participation16  
Effective mentorship of trainees by sending institution16,19  
Specific trainee prerequisites before approval for international rotation19  
Trainee preparation to enhance medical knowledge, skills, and cultural sensitivity and/or cultural humility12,19,50,51,54  
Positive attitudes and commitment of trainees52,53  
Significant investment (eg, engaging in robust predeparture preparation, self-financing travel) by trainee55  
Strengthening and standardizing program curricula to provide adequate medical and sociocultural preparation for visiting rotations at LMIC institutions56  
Adequate supervision of the resident while on the GCH elective Effective mentorship and supervision of trainees at sending and hosting institutions16,19  
Collaboration with LMIC partner sites that are teaching institutions with traditional faculty supervision57,69  
Provision of post-GCH elective debriefing Residents need support from home institution for the range of emotional responses they experience when returning from a GCH elective58  
Important postelective debriefing topics include the following: evaluation of the elective, sharing of the experience, knowledge translation, health and safety issues, reentry into the residency program59,60  
Establishment of ethical partnerships with host institutions, communities, and organizations that support the GCH electives and other educational opportunities Shared planning 
 Initial discussion and site visits between NA and LMIC partners, with explicit and transparent discussion about mutual benefits, costs, and financing16,50  
 Written agreements (such as a Memorandum of Agreement) with clear goals, objectives, and responsibilities16,61  
 Scheduled, frequent, real-time communication between partners to ensure that LMIC partner institutions have significant and frequent input throughout the program planning process16,50  
 Transparency between partnering institutions16  
Bidirectionality 
 Reciprocal opportunities for residents or other trainees from partner LMIC institutions to train at NA institutions34,57,62  
 Bilateral partnerships to foster longitudinal relationships, professional development, and capacity building34,51,68  
 Bidirectional opportunities, with faculty and trainees from NA and LMIC willing to both gain and share knowledge52,53  
 Share collective knowledge and resources between partners35,50  
 Opportunities for professional exchanges and mentoring35,64,66  
 Peer-to-peer collaborative relationships35  
Focus on long-term relationships 
 Continuous rather than intermittent interactions between LMIC and NA partners51  
 Strong mutual interest from both partners to cultivate a long-term partnership16  
 Long-term commitments to partners12,35,36,50,64  
Cultural and contextual awareness 
 Understand local disease epidemiology, medical conditions, health care systems, and cultural and/or sociopolitical considerations12,50,65  
 Train in ethical challenges and considerations12,65  
Equitable resource allocation 
 Partnerships should have equity66  
 Direct greatest share of resources to the less-resourced partner67  
 Work to achieve equity in health for all8  
Contribute to local professional development Support bidirectional learning opportunities for visiting and host trainees and faculty members during GCH electives22,27  
Evaluation Evaluation for program monitoring and improvement16,50,51  
Best PracticeSpecific Recommendations From the Literature
Adequate preparation and orientation of residents before departure on a GCH elective Careful selection and preparation of trainees for participation16  
Effective mentorship of trainees by sending institution16,19  
Specific trainee prerequisites before approval for international rotation19  
Trainee preparation to enhance medical knowledge, skills, and cultural sensitivity and/or cultural humility12,19,50,51,54  
Positive attitudes and commitment of trainees52,53  
Significant investment (eg, engaging in robust predeparture preparation, self-financing travel) by trainee55  
Strengthening and standardizing program curricula to provide adequate medical and sociocultural preparation for visiting rotations at LMIC institutions56  
Adequate supervision of the resident while on the GCH elective Effective mentorship and supervision of trainees at sending and hosting institutions16,19  
Collaboration with LMIC partner sites that are teaching institutions with traditional faculty supervision57,69  
Provision of post-GCH elective debriefing Residents need support from home institution for the range of emotional responses they experience when returning from a GCH elective58  
Important postelective debriefing topics include the following: evaluation of the elective, sharing of the experience, knowledge translation, health and safety issues, reentry into the residency program59,60  
Establishment of ethical partnerships with host institutions, communities, and organizations that support the GCH electives and other educational opportunities Shared planning 
 Initial discussion and site visits between NA and LMIC partners, with explicit and transparent discussion about mutual benefits, costs, and financing16,50  
 Written agreements (such as a Memorandum of Agreement) with clear goals, objectives, and responsibilities16,61  
 Scheduled, frequent, real-time communication between partners to ensure that LMIC partner institutions have significant and frequent input throughout the program planning process16,50  
 Transparency between partnering institutions16  
Bidirectionality 
 Reciprocal opportunities for residents or other trainees from partner LMIC institutions to train at NA institutions34,57,62  
 Bilateral partnerships to foster longitudinal relationships, professional development, and capacity building34,51,68  
 Bidirectional opportunities, with faculty and trainees from NA and LMIC willing to both gain and share knowledge52,53  
 Share collective knowledge and resources between partners35,50  
 Opportunities for professional exchanges and mentoring35,64,66  
 Peer-to-peer collaborative relationships35  
Focus on long-term relationships 
 Continuous rather than intermittent interactions between LMIC and NA partners51  
 Strong mutual interest from both partners to cultivate a long-term partnership16  
 Long-term commitments to partners12,35,36,50,64  
Cultural and contextual awareness 
 Understand local disease epidemiology, medical conditions, health care systems, and cultural and/or sociopolitical considerations12,50,65  
 Train in ethical challenges and considerations12,65  
Equitable resource allocation 
 Partnerships should have equity66  
 Direct greatest share of resources to the less-resourced partner67  
 Work to achieve equity in health for all8  
Contribute to local professional development Support bidirectional learning opportunities for visiting and host trainees and faculty members during GCH electives22,27  
Evaluation Evaluation for program monitoring and improvement16,50,51  

NA departments of pediatrics face challenges in developing and implementing successful GCH educational programs and collaborations. A primary challenge is the need for additional financial resources to support GCH education, including the recruitment and retention of GCH-dedicated faculty with protected time because the development and management of GCH education programs requires dedicated time and expertise. Financial resources are also essential in the formation and support of LMIC-NA educational partnerships, including support for LMIC partner faculty, infrastructure, and bidirectional opportunities as well as the provision of residents’ salaries during GCH electives.16,70 

Departments have generated funding for GCH education through the use of revenue from GCH clinical activities, such as travel, international adoption, and immigrant health clinics; leveraging research infrastructure in LMIC-NA partnerships to support education; and solicitation of philanthropic gifts.70 Smaller programs and those with limited funding can benefit from the growth in online GCH educational resources71,74 (see Supplemental Table 5 for examples of online resources) and from joining multi-institutional and regional consortia focused on LMIC-NA partnerships.70,75 

NA departments of pediatrics also face the challenge of ensuring their residents are adequately prepared clinically and culturally for GCH electives. Researchers describing LMIC institutions hosting US-based trainees have highlighted the problem of poor trainee preparation for situations that might lead to emotional distress, which can result in offensive or culturally insensitive behavior, and of conflicts with local practitioners that can arise when visiting trainees or faculty attempt to impose health care practices from the United States in resource-constrained settings.12,50,52,54,76,78 Despite the acknowledged importance of predeparture preparation, the 2014 survey revealed that only 66% of the US pediatric residency programs offering GCH electives provided predeparture preparation,20 with larger programs (>60 residents) more likely to provide preparation (89.7%) than smaller (<30 residents) programs (50%).20 In response, many pediatric residency programs and organizations have developed online GCH curriculum and predeparture orientation materials and made them available to other pediatric residency programs.71,74,79 

A third challenge faced by NA departments of pediatrics is meeting their responsibility to provide mutual benefit and reciprocity with their LMIC partners, particularly the challenges in developing bidirectional exchange opportunities for the LMIC partner trainees and faculty. NA-based trainees benefit from the expert teaching of LMIC colleagues with knowledge about diseases endemic to the area, history and physical examination skills honed from the use of these skills to make diagnoses in resource-constrained settings, and an understanding of the appropriate approaches to care for children in specific resource-constrained and cultural settings. In addition, they also typically receive hands-on clinical experiences during GCH electives, although barriers exist to offering reciprocal experiences to LMIC trainees participating in bidirectional exchanges. In the United States, requisite qualifications to allow hands-on patient care can make clinical training opportunities for visiting LMIC trainees challenging. Several institutions, particularly Canadian institutions, have succeeded in collaborating with university, hospital, and state certification agencies to allow for clinical opportunities for visiting residents under institutional agreements and with appropriate supervision.34 

In the United States, residency programs have worked to create meaningful bidirectional opportunities such as the exchange between Ann and Robert H. Lurie Children’s Hospital of Chicago and Bugando Medical Centre (BMC) in Tanzania, in which pediatric trainees from BMC are carefully integrated into a range of activities at Lurie Children’s Hospital, including broad clinical exposure and education opportunities such as conferences, teaching opportunities, and simulation training.62 The research from bidirectional opportunities reveals that LMIC trainees who participate in these exchanges or obtain qualifications in North America often return to their home country and become change agents promoting diagnostic and treatment techniques and educational approaches learned within NA training programs modified to be practical and appropriate in resource-constrained settings.33,62,80,81 Hosting NA institutions’ faculty and learners also benefit from LMIC trainees’ knowledge and experience in important GCH topics as well as learning from their different cultural view of medicine.62,63 To be effective, these opportunities must undergo careful review and ongoing evaluation by both the host and the LMIC institution to ensure institutional and educational goals are being met.

Clinical practice in GCH by NA pediatricians has previously often been limited to individual faculty members collaborating with LMIC sites, sometimes with the academic or financial support of their department, although more often by using the individual’s own time and resources.65,66,77,78 Increasingly, NA departments of pediatrics play a larger role in GCH clinical practice through clinical partnerships. Sustainable contributions of NA departments of pediatrics to GCH clinical practice in LMICs are rooted in collaborative partnerships in which the LMIC partner has the lead role providing guidance to the NA department in ways to collaborate to improve GCH clinical practice. For example, in situations when LMIC health systems are acutely stressed, such as postconflict and postdisaster situations or during disease outbreaks, NA departments of pediatrics have partnered with LMIC institutions and ministries of health to provide clinical care while also contributing to pediatric education, faculty development, mentorship, and strengthening of health care systems.42,64,66,82,86 These partnerships have used different models for clinical care ranging from NA-based faculty rotating to the LMIC partner site for 1 month83 to 1 year.64 In Supplemental Table 6, we provide several illustrative examples and brief descriptions of GCH clinical care partnerships.

In our literature review, we indicate a number of best practices for GCH clinical practice, including (1) the establishment of ethical partnerships with host institutions, communities, and GCH organizations characterized by shared planning,50,65 with a focus on long-term relationships12,35,37,50,64; cultural and contextual awareness12,50,65; and equitable resource allocation8,66,67; (2) alignment of clinical practice with local priorities*; (3) contributing to local professional development and pediatric care capacity35,37,40,50,67,83; (4) adequate preparation of NA-based clinicians12,50,52,54,67; and (5) ongoing monitoring and evaluation.50,51,69 In Table 2, we summarize specific recommendations from the literature for each best practice.

TABLE 2

Best Practices and Recommendations From the Literature for Engaging in GCH Clinical Practice

Best PracticeSpecific Recommendations From the Literature
Establishment of ethical partnerships with host institutions, communities, and GCH organizations Shared planning 
 Initial discussion and site visits between NA and LMIC partners with explicit and transparent discussion about mutual benefits, costs, and financing50  
 Written agreements (such as a Memorandum of Agreement) with clear goals, objectives, and responsibilities65  
 Scheduled, frequent, real-time communication to ensure that LMIC partner institutions have significant and frequent input throughout the program planning process50  
Focus on long-term relationships 
 Continuous rather than intermittent interactions between LMIC and NA partners51  
 Long-term commitments to partners12,35,37,50,64  
Cultural and contextual awareness 
 Understand local disease epidemiology, medical conditions, health care systems, and cultural and/or sociopolitical considerations12,50,65  
 Train in ethical challenges and considerations12,65  
Equitable resource allocation 
 Partnerships should have equity66  
 Direct greatest share of resources to the less resourced partner67  
 Work to achieve equity in health for all8  
Alignment of practice with local priorities Collaboration within the local health system (ie, local governmental health bodies, nongovernmental organizations, and/or private health institutions) to identify needs within the health system as potential target areas for partnership42,46,69  
Focus on addressing locally identified priorities37,42,50,51,66  
Work with community to improve health system rather than just providing care to community69  
Adapt treatments to local situations12,37,65  
Contribute to professional development and pediatric care capacity Investment in LMIC trainees, faculty, and staff35,37,40,67,83  
Training and mentoring in LMIC35,37,40,83  
Develop and support LMIC medical faculty50,67  
Adequate preparation of clinicians Enter partnerships with humility and solidarity67  
Faculty preparation to enhance medical knowledge, skills, and cultural sensitivity and/or cultural humility12,50,51,54  
Positive attitudes and commitment of clinicians51,52  
Evaluation Evaluation for program monitoring and improvement50,51,69  
Best PracticeSpecific Recommendations From the Literature
Establishment of ethical partnerships with host institutions, communities, and GCH organizations Shared planning 
 Initial discussion and site visits between NA and LMIC partners with explicit and transparent discussion about mutual benefits, costs, and financing50  
 Written agreements (such as a Memorandum of Agreement) with clear goals, objectives, and responsibilities65  
 Scheduled, frequent, real-time communication to ensure that LMIC partner institutions have significant and frequent input throughout the program planning process50  
Focus on long-term relationships 
 Continuous rather than intermittent interactions between LMIC and NA partners51  
 Long-term commitments to partners12,35,37,50,64  
Cultural and contextual awareness 
 Understand local disease epidemiology, medical conditions, health care systems, and cultural and/or sociopolitical considerations12,50,65  
 Train in ethical challenges and considerations12,65  
Equitable resource allocation 
 Partnerships should have equity66  
 Direct greatest share of resources to the less resourced partner67  
 Work to achieve equity in health for all8  
Alignment of practice with local priorities Collaboration within the local health system (ie, local governmental health bodies, nongovernmental organizations, and/or private health institutions) to identify needs within the health system as potential target areas for partnership42,46,69  
Focus on addressing locally identified priorities37,42,50,51,66  
Work with community to improve health system rather than just providing care to community69  
Adapt treatments to local situations12,37,65  
Contribute to professional development and pediatric care capacity Investment in LMIC trainees, faculty, and staff35,37,40,67,83  
Training and mentoring in LMIC35,37,40,83  
Develop and support LMIC medical faculty50,67  
Adequate preparation of clinicians Enter partnerships with humility and solidarity67  
Faculty preparation to enhance medical knowledge, skills, and cultural sensitivity and/or cultural humility12,50,51,54  
Positive attitudes and commitment of clinicians51,52  
Evaluation Evaluation for program monitoring and improvement50,51,69  

NA departments of pediatrics face multiple challenges in supporting clinical practice in GCH. As with GCH education, many departments face resource challenges including providing time, coverage, malpractice insurance, and salaries for faculty who pursue GCH clinical activities either through individual or departmental opportunities.70,85 In addition to the methods for generating funding described for GCH education, some departments have successfully obtained grant funding to support larger-scale projects and partnerships that include a clinical care component,64 although this remains a challenge for many departments.

NA departments of pediatrics also face challenges in forming and sustaining partnerships with LMIC partners, including ensuring that in addition to providing clinical care, there are efforts to participate in local professional development. Authors of previous literature have highlighted problems related to NA-based clinicians providing clinical care not linked to developing long-term clinical capacity in LMICs,50,67,69 most notably NA-based clinicians providing care that cannot be sustained after they leave (eg, treatments of chronic illnesses requiring access to medications and treatment) and clinical care projects that cannot be sustained once funding for the project has ended.12,65,77,86 

Departments have worked to address these challenges by incorporating an educational component as part of their partnerships. For example, in postconflict Laos, a multi-institutional partnership of the Lao University of Health Sciences, Case Western Reserve University, and Health Frontiers formed to deliver immediate postconflict pediatric care and codevelop a postgraduate pediatric training program in which most of the teaching is now provided by Lao staff.40 Additional educational models include “train the trainer,” in which NA-based clinicians train a local faculty member or provider who in turn trains their colleagues and other providers,69 and “twinning” models, in which an NA-based faculty member is paired with a local faculty member or provider and together they provide clinical care, each teaching the other as they work together.64 Professional development, like all things in GH, works both ways: LMIC practitioners provide substantial professional development to their NA faculty colleagues as well as NA trainees in how to provide clinical care in the LMIC setting.

A related challenge is addressing the adequacy of preparation of NA-based faculty members to practice in LMICs. Clinicians practicing in LMICs face challenges, including linguistic and cultural differences, working in an unfamiliar health care system with different resources, and practicing in a different context with clinical conditions and scenarios infrequently or never seen in North America.87 Researchers have previously shown that inadequate preparation can lead to clinicians delivering inappropriate care that does not adhere to local guidelines, cultural norms, or public health initiatives12,65,77 and being a burden to hosts who spend time orienting and supervising them.50,52 Individual faculty members are responsible for ensuring they are well prepared to practice in LMICs, and there are many resources and organizations that support clinicians in their preparation.87 Departments also have a role and should provide time and resources to prepare their faculty and provide context-specific, predeparture preparation for those participating in departmental or institutional partnership programs.42 

NA departments of pediatrics in partnership with LMIC institutions can play a role in advancing GCH research through the training of future NA and LMIC GCH researchers, developing and supporting individual NA and LMIC faculty members pursuing GCH research, and supporting the development of GCH research infrastructure. The training of NA-based GCH researchers in GCH-focused fellowships has increased over time; a review of pediatric subspecialty fellowships accredited by the Accreditation Council for Graduate Medical Education found that the number of fellowship programs offering GCH research training opportunities increased from 11 in 2008 to 28 in 2011.88 Proposed fellowship guidelines have also been developed,89 and the areas of GCH research training have expanded over time to include a number of subspecialties.

As with education and clinical practice, the most successful GCH research conducted by NA departments of pediatrics has been in long-standing collaborations with LMIC partner institutions and colleagues.90,91 Many of the longest-standing international collaborations, such as the collaboration between Moi University and Teaching Hospital in Kenya and a consortium of NA universities led by Indiana University, began as a collaboration in clinical practice focused on HIV care but have expanded to support research programs in multiple diseases and specialties, including pediatrics.90 Numerous examples exist of research conducted within GCH academic partnerships that have led to improvements in outcomes for children worldwide.11,92,95 In Supplemental Table 7, we provide several illustrative examples and brief descriptions of GCH research partnerships.

In our literature review, we indicate 4 main areas of best practices for engaging in GCH research: (1) establishment of ethical partnerships with host institutions that are characterized by mutual benefit, respect, and trust,17,37,61,90,96,102 clear communication,17,90,100 well-defined roles and expectations,17,101,103 and the practice of cultural awareness98; (2) alignment of research priorities with local and national priorities17,61,65,96,99,102,103; (3) contributing to local professional development and research infrastructure17,90,96,103; and (4) ongoing evaluation.17 In Table 3, we provide a summary of specific recommendations from the literature for each best practice.

TABLE 3

Best Practices and Recommendations From the Literature for Engaging in GCH Research

Best PracticeSpecific Recommendations From the Literature
Establishment of ethical partnerships with host institutions and collaborators Mutual benefit, respect, and trust 
 LMIC and NA partners should be equals17,90  
 LMIC and NA partners should have shared motivation, goals, and values17,90,100,101  
 Commitment to long-term relationships between LMIC and NA partners17,90,100  
 Common agenda, transparency, and accountability between LMIC and NA partners17,90,98,100,102,103  
 Shared academic credit, including joint-authored publications and presentations37,61,96,102,103  
Clear communication 
 Good communication skills between partners17,90,100  
 Scheduled site visits for LMIC and NA partners17,90  
Well-defined roles and expectations 
 Shared mission and vision between LMIC and NA partners17  
 Clear expectations set out at the beginning of the partnership17,101,103  
 Early planning with principal investigators17  
Cultural awareness 
 Deliberate effort needed to understand cultural aspects that affect collaborations and research98  
 Willingness to advise on culturally appropriate and inappropriate behavior98  
Aligning research priorities Common research agenda between LMIC and NA partners17,61,102,103  
Focus on local problems and locally sustainable solutions37,65,90,96,97,99,102,103  
Strategic alignment with national, partner, and GH priorities90,98,102,103  
Contribute to professional development and research capacity building Provide access to NA institutional seed funding for LMIC partners97,100  
Equity in training opportunities for LMIC and NA collaborators17,90,102  
Provide research training at partner site96,98,101,102  
Support leadership development of LMIC collaborators90,96,98,102  
Strengthen research infrastructure98,102  
Incorporate mentoring of LMIC collaborators and research trainees as part of partnerships97,99,101  
Evaluation Evaluation of research partnerships for ongoing improvement17  
Best PracticeSpecific Recommendations From the Literature
Establishment of ethical partnerships with host institutions and collaborators Mutual benefit, respect, and trust 
 LMIC and NA partners should be equals17,90  
 LMIC and NA partners should have shared motivation, goals, and values17,90,100,101  
 Commitment to long-term relationships between LMIC and NA partners17,90,100  
 Common agenda, transparency, and accountability between LMIC and NA partners17,90,98,100,102,103  
 Shared academic credit, including joint-authored publications and presentations37,61,96,102,103  
Clear communication 
 Good communication skills between partners17,90,100  
 Scheduled site visits for LMIC and NA partners17,90  
Well-defined roles and expectations 
 Shared mission and vision between LMIC and NA partners17  
 Clear expectations set out at the beginning of the partnership17,101,103  
 Early planning with principal investigators17  
Cultural awareness 
 Deliberate effort needed to understand cultural aspects that affect collaborations and research98  
 Willingness to advise on culturally appropriate and inappropriate behavior98  
Aligning research priorities Common research agenda between LMIC and NA partners17,61,102,103  
Focus on local problems and locally sustainable solutions37,65,90,96,97,99,102,103  
Strategic alignment with national, partner, and GH priorities90,98,102,103  
Contribute to professional development and research capacity building Provide access to NA institutional seed funding for LMIC partners97,100  
Equity in training opportunities for LMIC and NA collaborators17,90,102  
Provide research training at partner site96,98,101,102  
Support leadership development of LMIC collaborators90,96,98,102  
Strengthen research infrastructure98,102  
Incorporate mentoring of LMIC collaborators and research trainees as part of partnerships97,99,101  
Evaluation Evaluation of research partnerships for ongoing improvement17  

Specific challenges for NA departments of pediatrics in conducting collaborative GCH research include obtaining funding for GCH research, strengthening the research infrastructure domestically and in the LMIC, creating a supportive GCH research community, creating and maintaining LMIC-NA research partnerships, and navigating the bureaucratic, institutional, and governmental systems that govern GCH research.

There are multiple funding sources that can be used to support GCH research training for NA-based and LMIC trainees at all levels104,106 as well as LMIC-focused research awards that support research of importance in GCH.107,110 See Supplemental Table 7 for examples and brief descriptions of training and research grants. Departments can help grow GCH research by making departmental and seed grant funding available for GCH research, providing grant writing and preparation support relevant to GCH funding opportunities, providing administrative support for GCH researchers with expertise in issues such as international institutional review board processes and international contracts and payments, considering adjustments to promotion timelines because international research may take longer to conduct than domestic research, and considering adjustments to promotion guidelines to reward mentoring and collaboration with LMIC partners.111 

Faculty GCH researchers often feel isolated because they may be the only faculty member working in GCH in their division or department, particularly in smaller departments. In larger departments, GCH researchers may be scattered in different divisions and may not be aware of each other’s work and the potential for collaboration. Departments have addressed this challenge by creating divisions or centers of global pediatrics, which bring GCH researchers together, and by joining and supporting institution-wide centers for GH.111,112 

NA departments of pediatrics face particular challenges in meeting the best practice of engaging in GCH research that aligns with LMICs’ local and national research priorities. Funding for department-based GCH research is usually secured through NA-based principal investigators. NA investigators who are not fully engaged in a mutually beneficial partnership model of research with their LMIC collaborators may design research studies poorly aligned with local and/or national priorities, which may fail to substantially benefit local populations. US funding agencies are increasingly providing funding to projects with primary LMIC institutions and principal investigators and initiatives with clear partnerships between NA and LMIC institutions.113 

In addition to creating a shared research agenda, NA departments of pediatrics must address the challenge of making a clear commitment to supporting the professional development of LMIC researchers and research infrastructure as part of their partnerships.90,96,98,100,103 Failure to attend to these factors results in inequitable partnerships that hinder successful research and the development of long-term collaborations.17 Departments have promoted professional development and research infrastructure within LMICs by providing training either locally or online in core GH research competencies.114 NA partners have also offered access and support for LMIC collaborators to participate in certificate or degree programs91 and have provided training, professional development, and networking opportunities for LMIC research partners. NA partners must also acknowledge, highlight, and emphasize the value of professional development gained by NA partner researchers through learning from their LMIC colleagues.

In this review, we feature examples of how NA departments of pediatrics have successfully overcome challenges in engaging and expanding their role in GCH; however, challenges remain. NA departments should expand and strengthen advocacy efforts to address health equity. Specifically, advocacy is needed for the health concerns of diverse underserved children globally, for overcoming barriers to bidirectionality and mutual benefit in partnerships with LMIC institutions, and for greater research funding for GCH, with a substantial proportion of this funding going to LMIC institutions and investigators.

Additional work in monitoring and evaluation is also needed to better understand the outcomes in GCH programs to inform future improvements. Specifically, evaluations are needed related to the goals of health equity and improving child health, including evaluations to measure the extent to which GCH initiatives result in greater access to health services and interventions for all children; to assess the impact on trainees and faculty members of participating in GCH education and clinical practice experiences; and to monitor GCH-trained pediatricians’ career choices to provide health care to underserved populations and to monitor the discovery and dissemination of new interventions through GCH research. Health outcomes studies are also needed to determine the impact on US health outcomes of GCH-trained pediatricians and on health outcomes at partner sites to determine if collaborating with NA departments of pediatrics impacts local health outcomes. Finally, more evaluations of partnerships are needed with several proposed evaluation models.15,115 If goals are not being met, programs must seek to understand the issues impeding success and modify their programs to address these obstacles.

Adoption of the GCH best practices described in this review could lead to innovations in education, clinical practice, research, and advocacy efforts that reduce health inequity and improve health for all children. Through robust training and strong partnerships, departments of pediatrics can inspire the next generation of pediatricians to contribute to the often challenging but deeply fulfilling work of improving child health globally.

     
  • BMC

    Bugando Medical Centre

  •  
  • GCH

    global child health

  •  
  • GH

    global health

  •  
  • HIC

    high-income country

  •  
  • LMIC

    low- and middle-income country

  •  
  • NA

    North American

Drs Gladding and John developed the content outline for the manuscript, recruited the author team, conducted the literature review, drafted the introduction, methods, global child health clinical practice, and conclusions sections, and synthesized the first complete draft; Drs Summer, Russ, Uwemedimo, and Matamoros Aguilar contributed to the conception and design of the manuscript, assisted with literature reviews, drafted the global child health education sections, provided content expertise, and critically reviewed the manuscript; Drs McGann and Chakraborty contributed to the conception and design of the manuscript, assisted with literature reviews, drafted the global child health research sections, provided content expertise, and critically reviewed the manuscript; Drs Moore and Lieh-Lai contributed to the conception and design of the manuscript, assisted with literature reviews, drafted the global child health clinical practice sections, provided content expertise, and critically reviewed the manuscript; Drs Opoka and Howard contributed to the conception and design of the manuscript, provided content expertise, and critically reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

This paper is one of a series of papers conceptualized and produced by the Global Health Task Force of the American Board of Pediatrics. The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Board of Pediatrics or the American Board of Pediatrics Foundation.

*

Refs 12,37,42,46,50,51,65,66,69.

Refs 37,65,90,96,97,99,102,103.

FUNDING: Supported in part by the American Board of Pediatrics Foundation.

We thank the following contributors to this article: Valerie Haig of the American Board of Pediatrics for administrative support and Bonita Stanton, Virginia Moyer, and D. Wade Clapp for their thoughtful review of the manuscript. The following American Board of Pediatrics Global Health Task Force members are nonauthor contributors: Maneesh Batra, Sabrina Butteris, Christopher Cunha, Jonathan Klein, David Nichols, Cliff O’Callahan, Nicole St Clair, and Andrew Steenhoff.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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