The field that has now come to be known as global health has evolved substantially over the last fifty years. Driven by global pandemics such as HIV, increased foreign aid budgets from the U.S. and other high-income nations, the emergence of new multilateral institutions and NGOs such as the Gates Foundation, and increasing prioritization of country ownership of health programs, both the politics and the funding structure of global health work have shifted [1]. Global health has also experienced increased levels of attention and funding [2, 3]. Interest among students in high-income countries has increased as well, as evidenced by the impressive growth in the number of global health graduate programs [4, 5].

However, the influence of such changes on the global health job market has not been well studied, which has raised concerns about a potential mismatch between supply and demand [5]. Eichbaum et al. [4] initially explored this question with a pilot study of web-based job postings for global health employment opportunities; however, this provided only a “snapshot” of the current employment landscape, analyzing 178 job vacancies for positions based in low- and middle-income countries collected during two short periods, first in August 2013 and then again from November 2013 to January 2014. In order to gain a clearer understanding of the demands of the global health profession, and whether current training programs are adequately preparing students to enter the field, a more complete picture is needed of the current employment market. This includes the levels of experience, types of subject matter expertise, language and technical skills, and geographic experience required for available positions. To this end, we collected data on publicly posted global health jobs available to candidates authorized to work in the U.S. in order to characterize the skills and experience required for job applicants to be competitive for these positions.

The aim of this study was to provide a descriptive analysis of a large sample of job vacancies in the current global health job market captured over a six-month period.

A total of 1007 global health job vacancies from 127 employers were collected for analysis. Of the 1007 total job vacancies, 88% (n = 884) were positions listed by 126 distinct employers in the private or non-profit sector. The remaining 12% (n = 123) were U.S. government positions within six different federal agencies.

Our analysis of global health vacancies with both the U.S. federal government and private and non-profit organizations shows a substantial need for candidates with several years of experience with global health programs, particularly program managers/directors and technical experts. Nearly two thirds of all private and non-profit sector vacancies were for technical experts or program directors. Similarly, the majority (81%) of U.S. federal government positions were listed at General Schedule (GS) 13 level or higher. The highest level on the General Schedule that an external applicant can generally qualify for on the basis of education is GS-11, [10] or a GS-12 for some research positions [11]. Positions with GS levels from 12 to 15 are considered “mid- to senior-level” positions (Ibid). According to the classification standards for the public health program specialist series, the GS-13 position classification for the Public Health Advisor job series states that the role “require[s] advanced occupational expertise” and “provide[s] technical and administrative guidance necessary to resolve matters which are very controversial, complicated, or set general precedent.” [12]. This experience level could be considered the equivalent of that required for a technical or subject matter expert level position with a private or non-profit employer. Over one third of private and non-profit positions, and nearly half of all U.S. government positions, called for demonstrated experience in program management. Need for technical expertise in HIV/AIDS, monitoring and evaluation, and data analysis and management also emerged.

The thematic analysis also revealed a tendency for position scope to include, and for candidates to possess experience with, a wide variety of high-level and often unrelated responsibilities, including (but not limited to) stakeholder engagement, project design, data analysis, grant writing, financial management, technical training, and fundraising. It was not uncommon for job vacancies to call for candidates with thorough knowledge and/or multiple years of experience in four or more of such areas, many of which are quite specialized. While it may be more common for global health professionals in resource-poor settings to “wear many hats,” it is unlikely that recent graduates of global health training programs would possess skills or experience of this breadth.

In addition to analyzing global health job vacancies, we identified 27 U.S.-based MPH programs with a global health concentration in 2016. We reached out to all of the programs to learn what year their global health MPH concentration was established and approximately how many students graduated with a global health MPH each year. We received responses from 13 of the programs we identified, which estimated that a total of 280–300 students graduate with an MPH in global health from those programs each year. These figures represent less than half of U.S. global health MPH programs. Our analysis identified only 87 entry-level global health positions over six months, suggesting that that the number of global health MPH graduates entering the job far outstrips the number of entry-level positions available in a given year. Our findings echoing concerns among global health programs that jobs for their graduates are limited, and that the supply of graduates is outpacing the demand [3].

A substantial amount of academic attention and commentary has been paid to the development and assessment of competencies in global health education [13]. Such competencies are typically developed through a combination of literature searches, reviews of existing competencies taught by global health programs, and outreach to global health academic and professional communities [13, 14]. This process results in training programs in high-income countries using frameworks built through consensus with other training programs in high-income countries, and through review of literature published predominantly by research institutions in high-income countries, [15, 16] rather than the host countries in which the graduates of such programs ostensibly seek to work. Additionally, Eichbaum has observed that global health programs may use their competencies to establish a unique identity to compete with similar programs in attracting students, which serves the program’s own interests rather than those of local health systems in which their graduates would seek employment [13, 17]. Eichbaum suggests [13] that the reason that global health trainees from institutions in high-income countries so often experience difficulty in host country settings is that the training they receive is built on educational philosophies and values of the high-income country in which their institution is based, rather than the host country of the setting they wish to serve. This may help to explain why so many the vacancies we analyzed called for applicants with multiple years of experience. For our entire data set, the median number of years of experience required was five. Working and relationship-building in the global health profession is highly dependent on local contexts, [13] and employers believe that these skills can only be gained through related experience, as they are not adequately developed in global health education programs.

Our analysis included several limitations. First, it is possible that many of the job vacancies captured by our analysis may not have actually been available to external candidates. Employers may intend to fill a vacancy with an identified recruit or internal candidate, but are required by laws, regulations, or organizational policies to post the vacancy [18]. This is also true for hiring managers in U.S. federal agencies, who are required to fill civil service positions through “fair and open competition” but frequently prefer to hire internal candidates or, in some cases, do not open positions to external candidates at all [19]. A 2011 survey conducted by the U.S. Merit Systems Protections Board found that, in cases where positions were not opened to external candidates, the top reason, cited by 51% of human resources staff, was that there were “plenty of highly-qualified internal candidates.” Additionally, 38% indicated that hiring managers often already had someone in mind, and 18% responded that the expertise could not be found in the private sector, indicating the belief that only candidates with previous federal government experience could perform the job duties [14]. In our sample, global health vacancies posted by federal agencies often had the same position posted in a separate vacancy open only to internal candidates, so it is possible that the hiring manager already had an intended or preferred candidate for the position. Additionally, several of the positions were posted for an anticipated need. If project funding was interrupted or not renewed, or the contract bid not accepted, those positions may have never been filled and thus might not be representative of the job market.

Conversely, some vacancies for open positions may not be publicly posted. Non-government jobs can be filled through networks or recruiting efforts so that hiring managers can avoid sifting through applications from unqualified candidates. It is also possible that we did not capture all positions available in the global health organizations we targeted, as these employers may have posted jobs on boards or in locations other than the sites which we had access to, such as subscription-restricted job boards or listservs. In addition, our data collection period only spanned six months from November to May and therefore may not have captured possible seasonal hiring increases in the summer or fall. Finally, our analysis captured relatively few clinical practice positions such as physicians, nurses, dieticians, dentists, optometrists, and mental health practitioners. While it is possible that many clinicians who provide services in the global health field do so on an unpaid basis, we may also have not identified enough sources of paid clinical practice vacancies.

Overall, there were very few entry-level positions, those that might be accessible to recent graduates of a global public health program. Our findings echo concerns among global health programs that jobs for their graduates are limited, and that the supply of graduates is outpacing the demand [3]. Most employers in the global health field primarily hire technical experts and professionals with many years of experience in research or project implementation [2]. While the number of students graduating from global health training programs is increasing, the jobs most frequently sought typically require at least five years of field experience, making graduates unqualified to apply [5]. Furthermore, a recent survey of project directors at organizations implementing projects funded by the USAID Global Health Bureau found that two-thirds believed that MPH and global health programs did not adequately prepare students with non-clinical skills for the profession, [20] indicating that the training provided by global health graduate programs may not be well matched to the professional needs of the hiring market. This concern is underscored by the significant cost of U.S. global health MPH programs - a median of approximately $54,000 - which graduates will have to manage, in addition to any debt from their undergraduate programs. (This estimate is based on our identification of 27 MPH programs with a global health concentration in the fall of 2016. Median tuition was calculated based on graduate tuition for 60 credit hours.)

Global health training programs can help graduates prepare to work in global health by integrating an understanding of the global health career market into the curriculum and career assistance programs. Faculty and advisors should work with students to ensure realistic expectations of career prospects immediately upon graduation and provide concrete guidance on how to develop areas of technical expertise and cultivate a career for eventual entry into the global health field. Students should be coached on how to choose internships and practica that will provide experience that is valuable and directly applicable to their chosen career.

Universities that provide global health training programs have a responsibility not only to ensure that students and graduates are provided accurate information about career opportunities, but also to provide education and training that addresses unmet need in the global health field. Institutions should assess their curricula and training opportunities within the employment landscape. Additional research on the employment needs of the profession, such as key informant interviews with current global health practitioners, could strengthen the understanding of what is needed in the global health field and how aspiring global health professionals, and the programs that train them, can best meet the need to prepare a competitive global public health workforce and to help minimize a future workforce shortage.