A chance to Internationalize Medical Education

The global COVID-19 pandemic has presented opportunities for internationalisation of medical education (IoME). IoME promotes international healthcare understanding and cooperation, minimises healthcare nationalism and equitably improves the health of all people worldwide.

In line with the broader definition of internationalisation of higher education, it can best be described as the process of purposefully integrating international, intercultural or global dimensions into medical education in order to enhance its quality and prepare all graduates for professional practice in a globalised world.

Thus, physicians regard themselves as part of a worldwide medical community and solve healthcare issues in a collaborative manner. Although IoME is a global phenomenon, the understandings and perspectives of the Global North have traditionally dominated and therefore addressed only a narrow spectrum of activities transpiring globally.

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Motivations for internationalisation of medical education have focused on three major models. The first two, the market and social transformation models, have their limitations.

The market model: competition as a driver

With its focus on competition, the market model is often practised in low- and middle-income countries. Countries and institutions aim to improve their world ranking in science and clinical care through the lens of the Western world. Competition as motivation for internationalisation has immediate and measurable successes, but incurs the risk that, once certain achievement milestones are reached, interest in IoME is lost.

This model is characterised by inward thinking with respect to educational activities, which can foster, and result in, nationalism. This ultimately increases the risk of healthcare nationalism as countries try to compete for global leadership and disregard the common goal of improving the health of all people worldwide.

In addition, actors turn away when spotting a competitor in the market (as exemplified by the relationship between China and the United States in recent history). As such, the market model is rather unsustainable and its motivation is counterproductive to what IoME attempts to achieve.

The social transformation model: doing good

The social transformation model, dominant in the Global North and emphasising the humanitarian aspects of IoME, is rooted in altruistic and compassionate values. This model is predominantly realised via student outbound mobility, particularly to low- and middle-income countries (LMIC). However, this format does not fully realise the vision of social transformation of IoME in practice.

Research has shown that one-sided, short-term student mobility to LMIC, as currently practised in the Global North, is inherently unjust and not inclusive in many ways.

It tends to create a burden for the low-resource host countries and is ethically problematic when students are sent to a culturally diverse environment without proper preparation (for example, when medical students from the Global North volunteer to work in neonatal units in Sub-Saharan Africa).

There appears to be a lack of reporting on the voices of the Global South in the current body of literature.

Formats cater primarily to the needs of students from the Global North and mobility programmes are generally only accessible to a minority of privileged students at select institutions.

The above excludes the majority of students and thus is not in line with the vision of general accessibility in higher education. Furthermore, in times of pandemics and conflicts, these mobility programmes are not a safe way to educate students.

The liberal model: working on a common goal

The liberal model, adapted from other areas of higher education, fosters international understanding and collaboration via ‘soft diplomacy’. Medical education students act as goodwill ambassadors (for example, via the Fulbright or Rhodes programme).

However, current publications do not give evidence that this model is applied in medical education. Considered a by-product of the other two models, it has rarely been described as the sole or even partial motivation for international activities.

Therefore, an important purpose for globalising medicine has not been fully appreciated. In certain countries, it is now increasingly incorporated (for example, via the Erasmus programme), but innovative and socially equitable multilateral approaches, which consider the needs of the Global South as well as the Global North and provide students with a broader view of healthcare, are still limited in scope.

While the liberal model may not show an immediate effect on healthcare, given current events, with ongoing conflicts and nationalism in healthcare, IoME enacted through the liberal model can significantly facilitate international understanding and healthcare change and should be implemented further.

What comes next?

The COVID-19 pandemic has reminded us that healthcare nationalism limits us in improving the health of all people worldwide and prevents us from acting together as a global medical community.

It is important to educate our graduates to think differently. Medical educators need to look at their international activities through a different lens, with the liberal model in mind, and by educating our students to become ambassadors and global citizen physicians.

Formats of IoME need to be increasingly aligned with this motivation and purposefully integrate activities where students can participate in multilateral exchanges, learn how to understand and respect the practice of medicine in other countries in a culturally sensitive manner and feel that they are part of a global medical community without dominating others with their own, predominantly Western, views.

These activities can be virtual, include international student exchanges, shared international faculty members and joint teaching materials and can also occur through student mobility programmes where students act as ambassadors of their countries.

The above activities are equitable and aim to reach all students. A fundamental principle of internationalisation of the curriculum, and therefore of IoME, is the promotion of universal access to international experiences and education for all students.

Focusing on international activities ‘at home’ better reflects the tenets of IoME through a more inclusive approach wherein all medical education students, irrespective of socio-economic background, university of attendance or country of origin, gain access to experiences and content that have relevance beyond national borders.

Heightened healthcare nationalism is detrimental to the health of all people worldwide. With the support of IoME, healthcare providers view themselves as part, and act as members, of the greater global community. When international healthcare collaboration is promoted, healthcare nationalism wanes and the health of all people worldwide can improve.

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