In many countries the MPH is a desired pre-requisite for public health practice and research. However, few assessments of public health programmes for doctors were found except those reviewing American MD-MPH programmes, which may reflect the inadequate attention given to the subject.
Whilst it is not always possible for complete alignment between service organisations and training institutions, congruence between what is taught in the MPH and the requirements of public health practice ensures that the practitioners are ‘fit-for- purpose’.ii Inappropriate training is a concern,92 and a study involving seven countries (the UK, USA, Canada and some Asian countries) found a mismatchiii between what is taught and what is needed by organisations for 22% of competencies.108 Employers valued competencies such as “negotiation skills and contracting”, abilities to conduct “cost effectiveness analyses” and to “use legal and political systems to effect change”, whilst teaching institutions “favoured modules on communicable disease control, emergency planning and response, health needs assessment and organisational leadership and management”.
Internationally-driven programmes such as the Schools without Borders and international FETP were noted above,8 and the importance of addressing emerging public health problems, direct field work, experienced role models and integrating programmes into health ministry’s work of these programmes was highlighted. The international FETP global network of 47 programmes evaluated its programme to assess its impact on growing public health capacity and numbers of professionals.109 Half the students were doctors, with the remainder being epidemiologists (22%), veterinarians (9%), laboratory specialists (9%), pharmacists (3%) or another type of health professional (6%). Career paths of graduates sampled from one or two countries in each region showed high rates of local retention, with close to 70% working in governmental organisations for five years or more, with half working in health ministries.
A review of the Ugandan Public Health School without Borders MPH programme – which intended to increase technical, managerial and leadership skills to capacitate a decentralised health system – found that graduates occupied management positions at all levels of the services, in senior national ministry positions, in public health programmes, and were located in 85% of health districts, non-governmental
ii Suitable for the use for which it is intended.
iii They defined a mismatch as a greater than 20% difference in importance ratings between
organisations (NGOs) and private facilities.76 A minority worked outside Uganda. Most training (60%) was practical, through field mentors, supervisors and faculty
supervisory visits. Despite this investment, public health professionals remained scarce and the authors argued for a tenfold increase in the output of public health professionals for Uganda, and research that identifies the skills mix of public health workforce in low income settings.
A 2007 evaluation of seven cohorts of alumni of the University of Hanoi MPH programme found these mature graduates (mean age of 35.3 years at programme entry) mostly worked in the preventative health public sector (59%) – in training (75%), planning (72%) or in research (58%).110 The qualification resulted in promotion to leadership levels (heads of departments or institutions). They recommended that in addition to a strong research focus, more practical, management-based training was required.
A review of MPH alumni cohorts from the University of Geneva’s programme from 1991 to 2010 similarly found that for 57%, the qualification had advanced their careers, through job promotions.111 Forty percent of respondents were physicians. All alumni felt that the course gave them useful tools for later work, such as conducting literature searches, communication, evaluation and epidemiology. Respondents valued the networking opportunities and the multi-professional nature of the student body. The impact of trained public health professionals (doctors and others) in the Swiss health system was reported to have resulted in new public health policy and legislation, screening and disease surveillance programmes, improved management of hospitals costs, health promotion and improved local health programmes.85
For clinicians from high and middle income countries, broadening their perspective to appreciate the social determinants of health was the main value of the Oxford Global Health Masters’ programme that began in 2008. Interviews were conducted with 87% of alumni, 22% of whom were clinicians (physicians, medical students or nurses).112 Careers destinations were the focus of a 2003 review of the jobs of alumni of
American schools of public health which showed small proportions entering practice in local health departments “with most going into federal government, the FDA [Food
and Drug Administration], NIH [National Institutes of Health] and other academic institutions”.113 This may be the result of poor partnerships with health organisations, resulting in few practice placements and mentorship for departmental careers. Evaluations of MD-MPH programmes exploring motivations for public health training and longer-term career choices where public health training is an additional year intercalated in students’ medical studies, are outlined below.
An evaluation of the sponsored Macy programme at Columbia University’s Mailman School of Public Health, run from 1999 to 2007, focussed on motivations for enrolling and its impact on future career choices.114 Students enrolled from a range of New York City medical schools and motivations for studies included students wanting to gain a holistic understanding of the health care system, to understanding health in an international context and their desire to integrate public health concerns into clinical roles. Interestingly over half the Columbia students had prior public health training and many continued public health training after they completed the MPH. Reported skills sets acquired were in epidemiology-biostatistics (26%), research skills (26%), and health policy/systems skills (21%), and many said that they had acquired a “public health perspective”. Many used public health expertise in their work (93%) and these perspectives enhanced their ability to meet needs of patients (90%). Clinical careers from this programme and the one offered in Chapel Hill were in primary care fields of medicine, paediatrics, and obstetrics-gynaecology.115 The MPH gave direction and focus to careers, assisted with research skills, opened up international work
opportunities, oriented graduates to clinical and policy focused academic medicine, improved knowledge to shape policy, and some became committed to working with underserved populations.114
An earlier study exploring reasons for taking elective public health courses during undergraduate training at Columbia, found that an interest in health policy development, international health and, clinical prevention were important concerns.116 Encouragement from role models and coming from disadvantaged backgrounds were important motivators. Close to half completed the MD-MPH degree, and they believed this training enabled them to be marketable as clinicians,
researchers, managers or in occupational health careers and committee work. Epidemiology, policy and management skills were cited as most useful.
The impact of public health training on the long term career choices of physician alumni was assessed by the Tulane School of Public Health.117 Between 1985 and 1997, 17% of 1 108 physician graduates completed MPHs, and they were more likely to work in primary care settings, in public health practice and in research, particularly in lead positions in population-oriented research and dissemination than other physician graduates. The high proportion working as ‘physician-scientists’ (clinician researchers) was an unintended consequence of the MPH programme but may be the result of the research training gained in the MPH programme.
A review of employment of the first nine graduate cohorts (until 1997) of the only accredited Indian MPH programme, the Sree Chitra Tirnal Institute for Medical Sciences and Technology, found that although the MPH is not a required qualification for any position in India, all graduates obtained employment.118 Over 40% of
graduates worked for government health departments, 21% in NGOs, 16% in academic institutions and 10% with international agencies such as WHO or UNICEF. A national British study, exploring the career choices three to five years after
qualifying of 41 877 doctors graduating between 1974 to 2008, found that less than 1% (0.7%) of doctors gave public health as their first choice of eventual careers, with a majority of these being women.119 They entered specialist training several years after qualifying, later than other specialities. Compared to general practitioners, public health doctors’ decisions were motivated by “self-appraisal of own skills and aptitudes”; it suited their domestic circumstances, with “student experience of the subject” being less important, and “eventual financial prospects” were not important. These studies demonstrate that doctors embarked on postgraduate public health training for reasons that included broadening their horizons, developing skills that informed, shaped and advanced careers according to their aptitudes and interests. They were older and commenced postgraduate public health studies after a few years of practice. They valued skills in epidemiology, research, management and policy. Programmes that emphasised direct field work reported that alumni worked in local
health systems. Many graduates worked in the state health sector with notable
impact. Many became public health or clinical researchers, and in the USA, many have career paths in primary care clinical work.
2.3.3 Public health: The link between training, specialisation and the