title: Impact of MPH programs: contributing to health system strengthening in low- and middle-income countries?
abstract: The "health workforce" crisis has led to an increased interest in health professional education, including MPH programs. Recently, it was questioned whether training of mid- to higher level cadres in public health prepared graduates with competencies to strengthen health systems in low- and middle-income countries. Measuring educational impact has been notoriously difficult; therefore, innovative methods for measuring the outcome and impact of MPH programs were sought. Impact was conceptualized as "impact on workplace" and "impact on society," which entailed studying how these competencies were enacted and to what effect within the context of the graduates' workplaces, as well as on societal health.
  
  
  
  This is part of a larger six-country mixed method study; in this paper, the focus is on the qualitative findings of two English language programs, one a distance MPH program offered from South Africa, the other a residential program in the Netherlands. Both offer MPH training to students from a diversity of countries. In-depth interviews were conducted with 10 graduates (per program), working in low- and middle-income health systems, their peers, and their supervisors.
  
  
  
  Impact on the workplace was reported as considerable by graduates and peers as well as supervisors and included changes in management and leadership: promotion to a leadership position as well as expanded or revitalized management roles were reported by many participants. The development of leadership capacity was highly valued amongst many graduates, and this capacity was cited by a number of supervisors and peers. Wider impact in the workplace took the form of introducing workplace innovations such as setting up an AIDS and addiction research center and research involvement; teaching and training, advocacy, and community engagement were other ways in which graduates' influence reached a wider target grouping. Beyond the workplace, an intersectoral approach, national reach through policy advisory roles to Ministries of Health, policy development, and capacity building, was reported. Work conditions and context influenced conduciveness for innovation and the extent to which graduates were able to have effect. Self-selection of graduates and their role in selecting peers and supervisors may have resulted in some bias, some graduates could not be traced, and social acceptability bias may have influenced findings.
  
  
  
  There was considerable impact at many levels; graduates were perceived to be able to contribute significantly to their workplaces and often had influence at the national level. Much of the impact described was in line with public health educational aims. The qualitative method study revealed more in-depth understanding of graduates' impact as well as their career pathways.
authors.affiliation: Royal Tropical Institute, Mauritskade 63, Amsterdam, The Netherlands. P.Zwanikken@kit.nl.
authors.forename: Prisca A C
authors.initials: PA
authors.lastname: Zwanikken
authors.affiliation: School of Public Health, University of the Western Cape, Cape Town, South Africa.
authors.forename: Lucy
authors.initials: L
authors.lastname: Alexander
authors.affiliation: Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
authors.forename: Albert
authors.initials: A
authors.lastname: Scherpbier
mesh_terms: D001291:Attitude of Health Personnel; D003695:Delivery of Health Care / Q000592:standards; D003906:Developing Countries; D020375:Education, Distance; D004500:Education, Graduate; D040381:Education, Public Health Professional; D006801:Humans; D007182:Income; D020407:Internet; D007857:Leadership; D009426:Netherlands; D024382:Professional Role; D011634:Public Health / Q000193:education*; D015980:Public Health Practice; D036301:Qualitative Research; D013019:South Africa; D000078329:Workforce; D017132:Workplace
keywords: Evaluation; Graduate; Impact; Low- and middle-income countries; Master of public health