International Global Health Partnerships

How to explore and initiate an international partnership?

Any learner, faculty, staff or program member of NOSM University can initiate the exploration process for partnerships with institutions or organizations outside of Canada. This does not mean that NOSM University will automatically pursue a partnership–it is only an initial assessment to determine if a formal partnership with a prospective organization or institution should be established.

Should the prospective partnership intend to include relations with Indigenous Nations, it should not be explored without engagement and guidance from the Office of the Associate Dean, Equity and Inclusion.

Who should be informed during international partnership exploration?

If a learner, faculty or staff is initiating an exploration of an international partnership, they should first inform their respective program and academic reporting structure. For instance, before pursuing the partnership a PGY1 in Family Medicine must first notify their Site Director, then Program Director, and then the Associate Dean, Postgraduate Medical Education.

The Global Health Coordinator should be notified and can assist with the partnership exploration process. The Vice Dean of Research, Innovation and International Relations must also be informed of the prospective partnership. As the exploration continues, the Director, Planning and Risk will be contacted to provide support.

Should the partnership intend to include relations with Indigenous Nations in Northern Ontario, the Associate Dean, Equity and Inclusion, and other external parties representing Indigenous Nations, will be notified by the Global Health Coordinator.

International partnership exploration

Three-Step Assessment Process

The following three-step assessment process established by the NOSM University Advisory Group on Global Health and International Relations should be used to explore potential partnerships. The process includes identifying partners, ethical considerations, and feasibility, risk and sustainability. Once the three-step process is complete, the proposed partnership will be classified as Tier 1 (comprehensive) or Tier 2 (focused) as part of Step 3.

Step 1	Step 2	Step 3
Identifying Partners	Ethical Considerations	Feasibility, Risk & Sustainability
Who is this partnership with and how was it identified? (i.e. NOSM University or faculty, staff and learners or solicited partnership with NOSM University). Are there shared aspirations toward social accountability, values, academic principles and context? What do partner organizations and NOSM University have in common? What are their major differences?	Consider how introspection, social justice, humility solidarity, autonomy, beneficence and non-maleficence guide the partnership. What are the objectives, why is the partnership being pursued and how will it contribute to global health equity? Evaluate through a social accountability Lens. What are the cross-cultural considerations and impacts?How will this partnership be equitable? How will this partnership protect against harm?	Scope of partnership activities (Tier 1 vs. 2). Resource and financial requirements. Risk and benefit assessment. Institutional capacity to fulfill and sustain partnership obligations.

Each program is required to evaluate its desired partnerships using this framework. If necessary, a justification for a partnership may be called upon, amended and reviewed should challenges arise.

Once a decision is made to pursue a partnership, the program seeking the partnership, the Vice Dean, Research, Innovation and International Relations, the Global Health Coordinator, and the Director, Planning and Risk will work together to develop a detailed partnership framework through bilateral negotiations.

Should the partnership include relations with Indigenous Nations in Northern Ontario, negotiations with the respective external parties representing those Indigenous Nations will also be required depending on the nature of the partnership. This could include direct negotiations with the Indigenous community (i.e. Fort Albany) or an Indigenous Nation representative organization (i.e. Nishnawbe Aski Nation).

Step 1 – Identifying Partners and their Suitability to Partner with NOSM University

International partners can be found in different ways: by seeking them out, through existing relationships with faculty, staff, and learners, or by organizations that want to work with NOSM University.

When considering potential partners, NOSM University should think about whether they share a goal of being socially accountable, have similar values and academic principles, and are relevant to the context.

Reflective Question	Resources to consult
1. Who is the proposed partner and how was the partnership identified?	What is the source of partnership inquiry?
2. How does the organization demonstrate a commitment to social accountability?	World Health Organization’s Defining and Measuring the Social Accountability of Medical Schools.
3. What are the organization’s values?	Identify the partnership’s shared values. Check the partner organization’s website; vision, mission, purpose, value statements; strategic plan; organizational reports.
4. If this is an academic institution, what academic principles are identifiable and how does the institution realize its academic mission? (If this is not an academic institution how does the organization realize its mission?)	Identify the academic structure of the institution across health professional training programs, research and service delivery activities. Check the organization’s website; vision, mission, purpose, value statements; strategic plan; reports; organizational structure.
5. What is the geographical, cultural, racial, ethnic and socio-demographic context of the region the institution serves?	Describe the population and region the organization serves. Consider health equity stratifiers reflective of the Social Determinants of Health. Check the following sources: United Nations Sustainable Development Goals Country Profiles World Health Organization’s Global Health Observatory. The World Bank’s World Development Indicators database. Institute for Health Metrics and Evaluations Canadian Government Travel and Tourism
6. Will this partnership involve Indigenous nations in Northern Ontario and who else will need to be involved in this partnership?	Identify if there is interest in relations with Indigenous nations in Northern Ontario. Identify other Indigenous parties or organizations that will need to be engaged (i.e. specific community or representative organization). *Source*: NOSM University Office of Equity and Inclusion.
Summary Reflection How does this prospective partner organization compare to NOSM University? What do they have in common and what are the major differences?	Check the following sources: NOSM University’s vision, mission, purpose, strategic plan, and values. NOSM University’s Global Health Strategy and International Partnership Priorities document. NOSM University’s education model (distributed medical education, cultural immersion, rural focus, Indigenous, Francophone, Primary Care, etc.)

Step 2 – Ethical Considerations for International Partnerships

There are different ways to approach ethical appraisal in international partnerships, beyond what is outlined here. The NOSM University Advisory Group on Global Health and International Relations has identified important factors to consider, such as the organization’s vision, mission, and values. The aim of Step 2 is to establish an ethical basis for the partnership, while Step 3 covers institutional and personal risk and liability.

Consider ethical concepts such as introspection, social justice, humility, solidarity, autonomy, beneficence, and non-maleficence when answering these reflective questions.

Introspection: Examine your motives for the partnership and consider how privilege may affect them. Consider an anti-oppressive, anti-racist and anti-colonial analyses. Will the partnership contribute to the subjugation of the partner organization or developing/non-westernized countries?

Social Justice: How will the partnership help to create a more just society and reduce global inequality? Reflect on how the partnership will affect the global society, region, communities, people, and stakeholders.

Humility: What is the collective attitude towards our place in the world? Are we open to direction from the partner organization and avoiding colonial trends?

Solidarity: Are the partnership objectives aligned with the needs of the communities or regions? Do conflicting views of health and healthcare exist and why?

Autonomy: How will decision-making be respected, including that of the communities benefiting from the partnership?

Beneficence: How is the obligation to do good being fulfilled, and how is the partnership improving the well-being of others?

Non-maleficence: Consider potential harms and risks to others from the partnership. What steps are being taken to prevent harm, risk, unintended consequences, and prioritize safety and well-being?

Reflective Question	Resources to consult
1. What are the objectives of this partnership, why is it being pursued and how will it contribute to greater health equity?	What is the source of the partnership inquiry?
2. How does social accountability guide this partnership?	Identify the populations, communities and regions that will be served. Identify the health needs, social needs and health inequities that will be addressed. Identify how the values of relevance, quality, cost-effectiveness and equity will guide this partnership. Identify how community engagement and stakeholders from the WHO’s partnerships pentagram are involved in this partnership. Check the following sources: World Health Organization’s Defining and Measuring the Social Accountability of Medical Schools. Towards Unity for Health’s Challenges and Opportunities for Partnership in Health Development
3. What cross-cultural considerations and impacts need to be accounted for?	Consider how diversity, anti-racism, equity and inclusiveness can guide this partnership. Identify all ethno-cultural groups and languages spoken in the region the organization serves. Identify measures to achieve cultural safety and address ethnocentrism. Identify key differences from Canadian norms and values that may exist between medical care and related academic structures (i.e standards of care, resources, historical, religious, cultural and social norms, gender norms, political circumstances, laws, language, socio-economic, etc …). Check the following sources: Canadian Government Travel and Tourism
4. How will this partnership be equitable?	Identify how this partnership will move beyond informing towards empowerment. Identify how equity (not equality) is achieved. Identify areas of reciprocity. Check the following sources: International Association of Public Participation Spectrum of Public Participation
5. How will this partnership protect against harm?	Identify mechanisms that will prevent ‘brain-drain,’ ‘saviour complexes,’ voluntourism, ‘medical tourism’ and other unethical practices that exploit vulnerable populations.
6. Are there other important ethical dimensions and considerations?	Consider ethical lenses used in public health such as effectiveness, proportionality, necessity, least infringement and public justification.

References

Takala, Tuija. What Is Wrong with Global Bioethics? On the Limitations of the Four Principles Approach. Cambridge Quarterly of Healthcare Ethics: Vol. 10, Iss. 1, (Jan 2001): 72-7.DOI:10.1017/S0963180101001098
Andrew D. Pinto, Ross E.G. Upshur. Global Health Ethics for Students. (March 2009) Vol. 9, Iss 8. https://doi-org.proxy.lib.nosm.ca/10.1111/j.1471-8847.2007.00209.x
Solomon R Benatar,* Abdallah S Daar, and Peter A Singer. Global Health Challenges: The Need for an Expanded Discourse on Bioethics. PLoS Med. 2005 Jul; 2(7): e143. doi: 10.1371/journal.pmed.0020143.

Step 3 – Feasibility, Risks, Benefits, Sustainability and Type of Partnership

Step 3 will detail feasibility, benefits, risks, and sustainability and dictate whether the partnership should be pursued as Tier 1 (comprehensive) or Tier 2 (focused).

Tier 1 vs. Tier 2 Partnerships

Tier 1 Partnership

Tier 2 Partnership

Significant overlap in values, goals and contextual relevance.
Comprehensive in scope.
Covers education, research and service delivery.
Participation of UME, PGME and Health Sciences Learners; faculty across all divisions; and, researchers
Forward-thinking – NOSM as a standalone University
Very stringent partnership conditions

Limited overlap in values, goals, contextual relevance
Specific and focused in scope
Covers a limited number of specific activities in either education, research and service delivery
Limited participation of UME, PGME and Health Sciences Learners, Faculty and researchers
Forward-thinking – NOSM as a standalone University
Flexible partnership conditions

*Could develop over time into a Tier 1 Partnership

Reflective Question	Resources to consult
1. Describe the scope of the partnership and whether this should be considered a Tier 1 (comprehensive) or Tier 2 (focused) partnership. May revise partnership type as new/more information becomes available. *Partnerships can be fluid over time between Tier 1 and Tier 2.	Identify and describe the main activities of the partnership. Identify whether the partnership will involve education, research or service delivery (provide specific details for each domain). Identify whether partnership will include learners, faculty or staff (provide specific details). Consider what existing and/or additional responsibilities, resources and structures will be needed to meaningfully oversee and support the partnership. Identify a projected timeframe for the partnership.
2. Does NOSM University have the resources that will be required to meaningfully support this partnership for the projected time frame? Can the partner institution sustain this partnership?	Identify what human resources (staff, faculty, researchers, learners), physical resources and financial costs are required and whether that capacity currently exists. Linking human resources, physical resources and financial costs to specific activities of the partnership may help to understand what is sustainable for the projected time frame. Review and encourage the same from the partner organization.
3. What will be NOSM University’s financial and resource commitments? What will be the partner’s financial and resource commitments?	Create a budget that identifies projected financial costs and in-kind support provided by NOSM University. It may be practical to identify costs across the domains of education, research and service delivery and to consider a value analysis. Review and encourage the same from the partner organization.
4. What are the real, perceived or potential benefits of engaging in this partnership to NOSM University, learners, faculty, staff and partner?	Describe the benefits linked to the partnership’s main activities. Describe the benefits in terms of education, research or service delivery (provide specific details for each domain). Describe how the benefits will affect NOSM University as an institution, learners, faculty and/or staff (provide specific details).
5. What are the real, perceived or potential risks and liabilities engaging in this partnership to NOSM University, learners, faculty, staff and partner? How will these be mitigated?	Risks and liabilities may include, but not limited to, institutional reputation, medico-legal (medical licensing, malpractice insurance/risk), personal health and personal safety and professionalism. Consider risks and liabilities related to: NOSM University/institutional, Learners, Faculty and Staff. Institutional risks should balance the harms/benefits from association with countries and organizations based on human rights records, ethical and transparent financial processes, institutional accreditation, accountability, level and quality of supervision for learners, research ethics and other legal concerns. Personal health risks include: individual health concerns, as part of a health-care team, availability of health insurance (travel, health, life, disability) and ability to respond to a health emergency. Personal safety risks include: navigating an unfamiliar environment, VISAS / entry & exit requirements, travel advisories and medical malpractice insurance and ability to respond to a variety of emergencies (i.e. political instability, being detained or natural disaster). For each real or perceived risk detail how each will be mitigated and/or provide justification for accepting the risks in terms of the real or perceived benefits. Sources: Government of Canada ‘Canada to the World’(foreign policy, international development and relations) Government of Canada Travel Advice and Advisories Government of Canada Health & Safety Outside of Canada Canadian Embassies and Consulates CMPA providing care outside of Canada CDC Traveller’s Health Human Rights Reports: United Nations Human Rights Reports by Country Human Rights Watch Amnesty International United States Country Reports on Human Rights Practices
Summary Reflections Does NOSM University have the financial capacity to meaningfully fulfill and sustain its obligations for the proposed partnership timeframe? Are there any institutional, learner, faculty or staff risks and liabilities that cannot be reasonably addressed and that outweigh the benefits of this partnership? Based on the feasibility assessment should any adjustments be made to the scope of this partnership? Will the partnership be Tier 1 or Tier 2?

Next Steps

If the summation of the reflection and decision-making process is in favour of establishing a partnership, the next steps are to:

Inform the Global Health Coordinator and Vice Dean, Research, Innovation and International Relations of the findings.

Contact the Director, Planning and Risk if a formal, binding partnership agreement is desired.
Engage in bilateral negotiations that are transparent and allow the partner organization to be informed about all the details of the partnership and consent to it.

If relations with Indigenous Nations in Northern Ontario are being considered, you must also notify the Office of the Associate Dean, Equity and Inclusion. In addition to bilateral negotiations between NOSM University and the prospective partner, the respective Indigenous Nations must be directly involved in establishing this partnership.

View/Download:

NOSM University’s Global Health Strategy and International Partnership Priorities
International Partnerships Decision Support Framework