Liaw W, Bazemore A, Mishori R, Diller P, Bardella I, Chang N. The Financial Health of Global Health Programs. Fam Med 2014;46(9):672-678.
The Financial Health of Global Health Programs
Winston Liaw, MD, MPH; Andrew Bazemore, MD, MPH; Ranit Mishori, MD, MHS; Philip Diller, MD, PhD; Inis Bardella, MD; Newton Chang, MS
Background and Objectives: No studies have examined how established global health (GH) programs have achieved sustainability. The objective of this study was to describe the financial status of GH programs.
Methods: In this cross-sectional survey of the Society of Teachers of Family Medicine’s Group on Global Health, we assessed each program’s affiliation, years of GH activities, whether or not participation was formalized, time spent on GH, funding, and anticipated funding.
Results: We received 31 responses (30% response rate); 55% were affiliated with residencies, 29% were affiliated with medical schools, 16% were affiliated with both, and 68% had formalized programs. Respondents spent 19% full-time equivalent (FTE) on GH and used a mean of 3.3 funding sources to support GH. Given a mean budget of $28,756, parent institutions provided 50% while 15% was from personal funds. Twenty-six percent thought their funding would increase in the next 2 years. Compared to residencies, medical school respondents devoted more time (26% FTE versus 13% FTE), used more funding categories (4.7 versus 2.2), and anticipated funding increases (42.8% versus 12.0%). Compared to younger programs (≤ 5 years), respondents from older programs (> 5 years) devoted more time (25% FTE versus 16% FTE) and used more funding categories (3.8 versus 2.9). Compared to those lacking formal programs, respondents from formalized programs were less likely to use personal funds (19% versus 60%).
Conclusions: This limited descriptive study offers insight into the financial status of GH programs. Despite institutional support, respondents relied on personal funds and were pessimistic about future funding.
(Fam Med 2014;46(9):672-8.)
Interest in global health among medical students and residents has increased. According to recent surveys, medical school graduate participation in global health has increased from 20.2% in 2002 to 30.4% in 2012.1,2 Despite this growth, over a third of graduates (35.6%) rate their global health instruction as “inadequate.”1
Medical schools and residencies have responded to this increase in demand by expanding global health training opportunities.3 Such training has been associated with bolstering residency recruitment efforts, as well as participant improvements in tropical disease knowledge and increased confidence in physical exam skills.4-6
Unfortunately, making global health opportunities available is costly. In addition to costs borne by participants, faculty and their departments incur the costs of travel, lodging, in-country transportation, and supplies. Loss of revenue from time spent away from patient care can negatively impact departments and residencies, which are increasingly dependent on clinical income.7 As with most new educational endeavors, faculty must also devote time and resources to cultivating partnerships, designing courses, and evaluating curricula.
Global health educator conferen-
ces and listservs are consumed with discussions and inquiries about finding and sustaining finances for burgeoning global health programs. However, no singular path exists, and little has been written about the financial strength of global health programs or how established programs have achieved sustainability. Schultz et al reported that 29% of residencies with global health programs provided travel funding for residents in addition to continued resident salary support but did not specifically assess the amount of faculty support.8 The objective of this study was to characterize the financial status of family medicine-affiliated global health programs.
The study was initiated as part of the Group on Global Health’s (GOGH) SAGE project (Assessing the Social Accountability of Global Health Experiences), which was funded by the Society of Teachers of Family Medicine (STFM) Foundation. The survey targeted GOGH members and was initially distributed at two GOGH meetings at the STFM Annual Spring Conference in April of 2012. A link to an online version of the survey was sent to the GOGH listserv in July of 2012. Two reminder emails were sent to the listserv at approximately 1-month intervals. Respondents were not compensated for their participation. Any STFM member can join the GOGH, and there are no requirements that members practice global health. Based on our own Internet search to determine academic affiliations, the 189 GOGH members represented 45 residencies and 57 medical schools (six of which were outside the United States and Canada) at the time that the survey was released. For comparison, the American Academy of Family Physicians web site lists 83 residencies that offer international rotations.9
In this cross-sectional study, respondents completed a 32-item survey. The survey consisted of four sections: (1) background information about the respondent and the respondent’s primary institution, (2) the amount of faculty and staff time spent on global health activities, (3) sources of funding, and (4) the respondent’s perspective on the institution’s future global health funding.
To determine program characteristics, we asked about the program’s affiliation with medical schools and residencies, the number of years that the program had been in existence, and whether or not participation in global health activities was routine (indicating that the institution had a “formalized” program) or sporadic (indicating a “non-formalized” program). To assess measures of the program’s financial health, we asked about the number of funding sources used, the percentage of the total budget from each funding source, the annual budget amount, and the respondents’ financial outlook. We also assessed the time spent on global health activities, the number of partnering organizations, the number of global health activities offered, whether the program had access to administrative support staff and grant writers, planned mechanisms for expanding funding, and methods used for learning about new funding opportunities. Respondents also provided information regarding their position within their academic institution, the duration of their tenure there, and their familiarity with the global health activities at the institution.
Due to the small sample size and convenience sampling, we did not conduct a statistical analysis of these descriptive data. This analysis was approved by the Institutional Review Board of the American Academy of Family Physicians.
We received responses from 31 institutions, for a response rate of 30% for the 102 unique GOGH institutions. Fifty-five percent of the respondents were affiliated with only residency programs while 29% were affiliated with only medical schools. Sixteen percent were affiliated with both medical schools and residencies. In two instances, respondents were associated with the same parent universities, with one affiliated with the residency program and the medical school and the other affiliated with only the residency program. We considered these to be different institutions since the funding streams for medical schools and residencies are often different.
Respondents worked at their primary institutions for a mean of 8.8 years (range 1–34 years). Twenty-four respondents (77%) self-identified themselves as the director or leader of global health activities at their respective institutions, having been in that role for a mean of nearly 5 years. The remaining respondents were program directors (two), faculty (five), and one resident still in training.
Global health activities started at these institutions a mean of 10.9 years ago (range 1–42 years). Sixty-eight percent indicated that their institutions had a formalized global health program, center, or track, which started a mean of 8 years ago (range 0-27 years).
Respondents spent 19% full time equivalent (FTE) (range of 2% to 36% FTE) working on global health projects, with 13% being spent on administrative and research tasks (range of 0% to 40%) and 6% being spent traveling abroad (1 week abroad in a 50 work-week year equals 2% FTE; range of 0% to 20%). Twelve (39%) respondents reported having administrative staff to assist with projects. Only two respondents (6.5%) had grant writers. The global health curricular components and partners of the institutions are listed in Table 1.
Of the 14 possible funding streams, respondents reported using a mean of 3.3 sources. Twenty-one (68%) reported using funds from their parent institutions. Thirty-two percent reported that at least some of their efforts were not supported by any revenue but rather were done on personal or vacation time. Family members, fundraising events, community organizations, alumni, and travel scholarships were the next most frequently cited sources outside of parent institutions and personal funds.
The mean total budget for global health activities was $28,756, with $10,524 spent on trainee expenses (including travel and salary support), $18,544 spent on faculty expenses (including travel and salary support), and $3,818 spent on department expenses (including fundraising, administrative support, and expenses associated with maintaining an international site). We excluded one outlier with a budget of over $1 million.
Respondents also estimated the percentage of their budgets that were derived from each funding stream. Given a mean budget composed of the participant responses, parent institution funding provided 50%, though the type of funding was not specified. Fifteen percent of the average budget was funded by “in-kind” donations (ie, from personal or vacation time).
On average, respondents slightly disagreed with the statement that their global health activities were “adequately funded” to meet their aims and objectives—3.3 on a scale where 1=strongly disagree and 7=strongly agree. They also slightly agreed with the statements that they were concerned with their “ability to sustain their global health activities over the next 2 and 5 years” (4.6 and 5.0, respectively). Eight respondents (26%) indicated that they thought that their level of funding would increase in the next 2 years, while six (19%) thought their level of funding would decrease in the next 2 years.
When asked about the methods used to keep informed of new funding opportunities, 21 (68%) reported not having a specific mechanism. Two (6.5%) used funding listservs while two (6.5%) asked global health colleagues. Only one (3%) had a dedicated person to assist with finding new funding opportunities.
With respect to the mechanisms respondents planned to use to expand funding, 11 (35.5%) reported that they planned to pursue federal grants within the next 5 years to increase funding, while 12 (38.7%) planned to pursue private grants. Four (12.9%) planned to increase their fundraising efforts, while three planned to start 501(c)(3) organizations (nonprofits). Nine (29%) reported that they did not know what they would do to pursue funding opportunities or had no further plans to pursue funding.
Those affiliated with medical schools (including those working at both medical schools and residencies) partnered with more types of outside organizations (3.1 versus 1.3) and devoted more time to working on global health activities (26% FTE versus 13% FTE) than those affiliated with residency programs alone (Table 2). Medical school-affiliated respondents were also more likely to report having administrative support personnel (64% versus 17%), used a greater number of funding categories (4.7 versus 2.2), and anticipated their funding to increase in the next 2 years (42.8% (versus 12.0%).
Compared to younger programs (those in existence for 5 years or less), those from older programs (in existence for more than 5 years) reported higher percent FTE devoted to global health activities (25% [95% CI=13.0%, 32.0%] versus 16% [95% CI=11.0%, 20.0%]), more funding sources (3.8 [95% CI=2.9, 4.9] versus 2.9 [95% CI=1.7, 4.4]), and larger budgets (Table 2). For this analysis, we excluded five respondents that indicated they “did not know” when global health activities started at their institutions.
Differences also existed between institutions that had started a self-identified formalized global health program, center, or track with “routine participation among trainees and faculty” compared to those who had no such formal program where “participation was sporadic.” Compared to those who lacked formal programs, respondents from institutions with formalized programs reported partnering with more types of outside organizations (2.6 versus 1.1) and were less likely to report having to use personal funds (Table 2).
Responding institutions revealed considerable support of global health activities. On average, global health programs spend over $28,000 annually, with half of the budget coming from parent institutions. Since the second largest contributor to the mean budget was use of faculty personal funds and time, global health educators expressed concern regarding future funding for endeavors and were pessimistic about the potential for increases in funding.
The financial outlook and health of global health programs varied based on several characteristics though these trends will need to be assessed in larger studies using a more representative sample to determine whether these differences are reproducible and reach statistical significance. Compared to those affiliated with only residencies, respondents affiliated with medical schools tended to report more partnering organizations, revenue streams, and time spent dedicated to global health activities. Educators at institutions with formalized global health tracks tended to have more partnering organizations and were less likely to report having to rely on personal funds.
Several factors could explain our findings. First, departments of family medicine within medical schools benefit from connections with other academic divisions, allowing for economies of scale and collaboration. For example, global health administrative staff expenses could be distributed among several departments while this arrangement may not be possible at residencies not closely aligned to medical schools. Inter-department collaboration within medical schools could also extend to revenue-generating activities, allowing medical school global health programs to aim for more ambitious fundraisers or apply for larger grants. Departments of family medicine within medical schools may also have larger budgets than residencies, though we are unaware of any studies documenting this difference. Unfortunately, this study cannot determine whether these factors contributed to increasing financial sustainability or were consequences of program success.
Formalizing and declaring aims and objectives for global health tracks or programs may also be a contributing factor to the success of those programs. The inherent pressure that publicly declared goals place on educators to seek out partners and uncover new revenue streams may explain this finding. Absent an explicit mission, involvement in global health may wax and wane depending on the interest of learners.
Ultimately, we report on a convenience sample drawn from a self-defined and self-selected cohort of individuals affiliated with global health programs. The effect of this selection bias on our data cannot be determined but is potentially substantial. Thus the following limitations should be taken into account when interpreting these findings. First, our response rate was low. Nevertheless, we contend that only a subset of GOGH members is likely to have accurate knowledge regarding institutional global health budgets. For instance, a faculty member at a residency program who has participated in an isolated global health experience may not know the amount of residency money allocated to global health activities. Therefore, a higher response rate would not necessarily be associated with more accurate results. Second, we report on a convenience sample drawn from a self-defined and self-selected cohort of individuals affiliated with global health tracks and programs. These data may not be representative of all family medicine global health programs.
Third, the responses are subject to recall bias and subjective estimations of the resources allotted to global health training. Respondents may not have accurate knowledge of the exact amount of money devoted to these activities, though 77% of the respondents are self-identified directors of global health activities at their institutions. Fourth, many respondents have multiple institutional affiliations (ie, they work for a medical school and a residency program), and there may have been discrepancies between how these faculty responded to the questions. Some may have reported the activities of the residency program only, while others may have reported the combined activities of the residency program and the medical school. Fifth, this survey only assessed family medicine contributions; thus, we cannot draw conclusions about medical schools in general or residencies in other specialties. These results do not capture the input of the numerous global health programs led by those in other specialties.
Finally, the fact that some participants left answers blank may limit the accuracy of our results, though it is unclear that obtaining more responses would necessarily yield more accurate data. We contend that this is a finding as well. Many young global health programs struggle to implement curricula and may lack the resources to track the expenditures and opportunity costs associated with these experiences.
This limited descriptive study was meant to be the first step in exploring this important topic. Future research should focus on obtaining more responses from existing global health programs, at both the medical school and residency levels, from global health leaders in other specialties and from chairs and deans who may have different perspectives on global health expenses. Qualitative research on how successful programs were able to grow can uncover specific steps and best practices that were taken to achieve sustainability.
Acknowledgments: This work was supported by the Society of Teachers of Family Medicine Foundation’s Group Project Fund.
Corresponding Author: Address correspondence to Dr Liaw, Virginia Commonwealth University, 3650 Joseph Siewick Drive, #400, Fairfax, VA 22033. 703-391-2020. Fax: 703-264-9861. firstname.lastname@example.org.
From Virginia Commonwealth University (Dr Liaw); Robert Graham Center, Washington, DC (Dr Bazemore and Mr Chang); Georgetown University (Dr Mishori); University of Cincinnati (Dr Diller); Rosalind Franklin University, North Chicago, IL (Dr Bardella).
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