of those trained never return home, many of those who 

 do return do so as specialists trained to practice a 

 sophisticated kind of medicine inappropriate to 

 priority needs, and many return with life-style 

 expectations and income demands such that their 

 services are effectively denied to most of their 

 compatriots. 



Despite these problems, many developing country 

 physicians trained in affluent countries have played 

 crucial roles in the transfer of health, nutrition, and 

 family planning knowledge and technology. Universities 

 such as City College of New York and Ben Gurion 

 University in Israel have undertaken programs 

 specifically directed at training physicians in primary 

 health care. The record of physicians trained in 

 schools of public health in the United States and 

 elsewhere may be better than that of those trained as 

 specialists in hospitals because of the greater concern 

 of the public health profession with community-related 

 problems. 



Proposed Initiatives 



Much of the knowledge and technology at issue have 

 existed for years and a variety of implementation or 

 transfer mechanisms has been tried. Many of these 

 mechanisms have worked well on a small scale; fewer 

 have been effective on a large scale. Yet we have done 

 little to learn from these trials. 



We propose that the United States encourage 

 international support for an expanded program of 

 concrete demonstrations of feasible, effective, 

 reproducible ways in which health care systems can be 

 improved. This is proposed despite a somewhat 

 disappointing past record of replicating successful 

 pilot and demonstration projects (for a recent review 

 of experimental efforts in the family planning field, 

 see Cuca and Pierce 1977) . 



Such demonstration projects should be carried out 

 jointly by both developed and developing countries and 

 funded in such a way that the project can be replicated 

 on a broad scale with local resources once the initial 

 period is past. Most likely, developing countries will 

 be represented by governmental institutions, but 

 wherever possible private organizations, medical 

 education and training institutions, and service 

 agencies should be included in order to stimulate the 

 long-term institutional development on which broad- 

 scale replication ultimately depends. 



On the developed country side, the approach might 

 be bilateral or multilateral, through one of the U.N. 

 agencies or the World Bank; large resources will be 



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