Working in Low and Middle Income Countries

Report of a Workshop held 6 July 2011 - Pierian Centre, Severn Deanery

This one day workshop aimed to bring together trainees and educational supervisors and Heads of schools to explore the benefits and pitfalls of trainees undertaking time working low and middle income countries (LMICs) during their training programme, and to explore ways in which Severn Deanery might facilitate and support this process. Presentations were made from both individual trainees and training programmes who have had experience of working in these settings, and/or who are developing institutional links and on-going programmes. At present, a limited number of trainees (5-7 per annum) undertake out of programme experience (OOPE) in a LMIC, and perhaps 10-20 are undertaking more time limited opportunities which do not require OOP, although no specific details are held in the deanery.


There was agreement from trainees and educational supervisors that working in LMICs has enormous potential to help trainees broaden their horizons, enable them to learn clinical, organisational and leadership skills, and to undertake research, as well as making a direct contribution. The development of confidence, maturity, a broader vision, decision-making, non-clinical skills, communication, practical skills, different ways of thinking, and an openness to different way of doing things were cited as potential benefits.

These opportunities can help develop trainees who are well prepared to contribute to the skills that they have learnt to the UK healthcare system. Whilst a number of these benefits are also provided by experiences of working in other healthcare systems in high income countries, it was felt working in LMICs also provides additional challenges and insights into global health issues that means that this is a qualitatively different experience.

Many specialty curricula now cover global health issues, and increasingly there is a convergence of health problems as both high and LMICs deal with the increasing burden of non- communicable diseases (NCDs) on premature morbidity and mortality. This means that some of the experience gained in these settings can be directly applied to the UK specialty curricula.

However, more generally, these opportunities can help trainees develop as global citizens, and help both individuals and programmes develop an awareness of the issues of inequity in healthcare and the role of the profession in championing these inequalities.

The issues are well described in the report: Global health partnerships: the UK contribution to health in developing countries. Nigel Crisp. Department of Health. London 2007.


Working in LMICs can be challenging, stressful, and local support can be variable. Healthcare systems may be chaotic and individuals may not be able to make as full contribution as they would wish. Partnerships take time to be developed and need to be sustained; one off collaborations are unlikely to generate benefits for either party.

Established Links

A number of links and partnerships of variable depth and longevity are already in existence within the Severn Deanery; some of these relate to institutions and some to individuals. Examples include:

  • Makerere Medical School, Uganda and University of Bristol
  • Zanzibar Medical School and School of Emergency Medicine and Somerset Partnership Trust
  • International Nepal Fellowship – Ear Camps in Darchula, North West Nepal
  • MEAK- Medical and Educational Aid to Kenya – primarily paediatric cardiac surgery but now extending to ophthalmology
  • Kilifi, Kenya, paediatrics
  • BEIT CURE Trust International Hospital (BCTIH) paediatric orthopaedic hospital in Blantyre, Malawi

There will be further links between Trusts and individuals of which we are not aware.

Following presentations from individuals of experiences, participants broke into workshops to discuss how and if the Severn Deanery might facilitate experience for trainees interested in this working in LMICs.



  • A high level policy statement on the Deanery website indicating support for trainees in principle to gain experience in LMICs should be written and visible.
  • An area on the website should be developed to profile and highlight work undertaken by trainees in LMICs in Severn, together with useful links and information
  • The Deanery should ask all Schools to have a section on their websites on international links, and should be asked by the Deanery to include a section in their annual report on this topic.
  • The Deanery should explore with UoB and UHB if the existing links with Makerere in Uganda can be further exploited

Heads of Schools/Training Programme Directors

  • Heads of School/Training Programme Directors should be encouraged to consider developing sustainable links within programmes to offer opportunities for trainees in their areas. This should include a range of opportunities eg short term opportunities that do not require trainees to take OOPE, but could be accommodated within annual leave/study leave; OOPE, and in some cases (probably exceptional) OOPT. There may be particular benefits in embedding short-term placement in long-term programmes that could be made relatively widely available within programmes to a larger number of trainees than could practically undertake OOPE. This also minimises service disruption. As orking in LMICs requires reciprocal registration with regulatory bodies, short term placements with a focus on teaching may obviate the need to register with the ensuring bureaucracy but allow highly relevant experience
  • Each school should develop an international section on their website, that would profile these opportunities, together with reports from trainees who have completed them. This could include video links/YouTube and contact details if trainees are willing to provide these to other trainees. The School of Primary Care is already pioneering this.

Deanery and Schools

  • Consideration should be given as to how to best to briefing individuals before going, provide mentorship whilst on placement and also debriefing them on return. There are a range of practical key issues such as NHS pensions, continuity of service, anti-retroviral treatment, which need to be carefully considered. There are a number of courses running which aim to prepare health professionals for working in LMICs; these could be profiled on the deanery website.
  • Consideration should be given as to how provide trainees with opportunities for feeding back/profiling their work eg specialty seminars, a deanery pan speciality annual seminar/presentation for trainees and educational supervisors/programme leaders to share experiences.
  • Whilst it is not unreasonable to ask trainees to make a financial contribution towards the costs of placements in LMICs, Schools and Deaneries should try to ensure that they are not shouldering a disproportionate burden. Severn Deanery and Medical School should consider establishing charitable fund ie. for flights 50:50 split with trainees to support this work. Wherever possible fund raising should take place by building on established organisational partnerships or charities which means it is both easier to fund raise and to apply for grants
  • Flexibility: schools and the deanery should take a supportive but critical approach to approving both OOPE and study leave experience in LMICs asking four questions: what is the benefit to you? to the country you are visiting? To the NHS? And why is now the time to do this?
  • Flexibility within ARCP processes needed with respect to extending training programmes by approval of OOPE
  • Flexibility by HoS in use of study leave time and funding can allow creative use of opportunities
  • Trainees are more likely to have a positive experience if formal pre-arranged programmes with established links are used- although at the outset they may feel that they would prefer to establish new links; explore if links with (non medical) large companies might provide logistic support
  • Trainees need to be clearer in documenting outcomes from placements in LMICs and sharing benefits and learning
  • For placements to be successful there must a real understanding of local context and conditions such as pay, workload, resources; health care worker migration (“brain drain”). The need to consider sustainability issues at the beginning of a partnership, and who is responsible for doing this needs to be embedded. Issues such as exchange visits may need to be considered. Identifying the right people is critical- and recognising that an over-reliance on technological solutions is likely to be extremely frustrating is essential.

Professor Selena Gray
Deputy Postgraduate Dean
Severn Deanery
July 2011

 Here are some recent examples of OOPE placements..