NETWORK THE TOWARDS UNITY FOR HEALTH
VOLUME 24 | NUMBER 01 | JUNE 2005
“DECEMBER 26, 2004 will be forever imprinted in Thai minds,” says Nitaya Wongsangiem, a Network: TUFH member from Thailand. Nitaya and members from India and Indonesia describe in three impressive articles the impact that the tsunami had on their country and their countrymen, as well as the (Governmental and non-govermental) medical aid that has been provided since that fatal day. You read the stories about the disaster, but its magnitude and terror remain incomprehensible. Then and now, we as members must be there for each other, or as Arthur Kaufman says to our colleagues in the affected regions: “The Network: TUFH includes member institutions which themselves may be able to assist you by supplying materials. I encourage you to share your needs to overcome the consequences of the tsunami with the Network: TUFH office and we promise we will do everything we can to identify resources or partners apt to assist you.” (page 3) Marion Stijnen and Pauline Vluggen Editors
In the Newsletter we refer to The Network: Towards Unity for Health as The Network: TUFH.
THIS NEWSLETTER HAS BEEN PRODUCED IN COLLABORATION WITH WHO
NEWSLETTER IN THIS ISSUE, AMONG OTHERS: Position Paper: Integrating Medicine and Public Health 06 Tsunami: The Killing Wave 18 An Action Plan for Rural Health 19 Community-Based Education in Brazil 24 Family Medicine Network: Connecting Southern and Eastern Africa 32
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CONTENTS 03 Foreword Reaching Out, Sharing Complementary Strengths | Helping Hand 04 The Network: TUFH in Action 04 Annual International Conference ‘South-North’: Collaboration Nepal - Netherlands | The 2005 Conference | Participate as an Exhibitor and/or Co-Sponsor 06 Position Paper Integrating Medicine and Public Health | An Overview of the Position Papers | Reviewing Position Paper on Primary Care: Revolution Starts With the Middle Class | Position Paper News 15 Book Review Challenging But Not Comfortable Reading 16 Education for Health Transition | Education for Health Online | New Editors Education for Health 18 Improving Health 18 Health Services Tsunami: The Killing Wave 19 Rural Health An Action Plan for Rural Health 20 Health Research Empowerment of the Community in Health Action Research 21 Health Authorities “Normality is Still a Long Way To Go” 22 Health Professions Jogjakarta Medical Rescue for Aceh 23 International Health Professions Education 23 Multiprofessional Education Interprofessional Education Moves Forward in Canada 24 Problem-Based Learning and Community-Based Education Community-Based Education in Brazil 25 Rural Health Professions Education Women’s Arms and Skills for a United Community 26 Distance Learning The Culture of Distance Learning...It’s Not About Technology! 27 New Institutions and Programmes International Master in Affective Neuroscience 27 Community Action 27 Community Interview Community at the Heart 28 Students’ Column 28 Out of the SNO Pen Sharing in Atlanta 28 International Diary 2005 and 2006 30 Member and Organisational News 30 Messages from the Executive Committee General Meeting 2005, Vietnam | New Executive Director GHETS 32 Represented at International Meetings/Conferences Family Medicine Network: Connecting Southern and East Africa | Advertising in the Alert 33 Taskforces The Women and Health Learning Package: A Review 34 Re-assessing Full Members “To Be a Centre of Excellence” 35 About our Members Hubbard Award for Cees van der Vleuten | Moving on: Changes in Leadership | Students Honour | New Members | Members Helping Members | Interesting Internet Sites | John Hamilton Delivers Network: TUFH Lecture
FOREWORD
Reaching Out, Sharing Complementary Strengths This past year, in my role as Secretary General of The Network: TUFH, I was invited to sit on the Board of the Foundation for the Advancement of International Medical Education and Research (FAIMER). This is a non-profit foundation of the Education Commission for Foreign Medical Graduates (ECFMG) in the United States.
I encourage you to share your needs to overcome the consequences of the tsunami with The Network: TUFH Office and we promise we will do everything we can to identify resources or partners apt to assist you.
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On behalf of The Network: Towards Unity for Health Arthur Kaufman | Secretary General
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I’VE BEEN STRUCK BY THE RICH DISCUSSIONS ABOUT PHYSICIAN MIGRATION AT FAIMER BOARD MEETINGS.
As we all know, The Network: TUFH is not a funding institution. However, it can identify experts and it includes member institutions which themselves may be able to assist you by supplying materials.
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Arthur Kaufman | Secretary General Email: akaufman@salud.unm.edu
In December last year we were all shaken by the consequences of the tsunami, and emails were exchanged among Network: TUFH affiliates to comfort our colleagues in the affected regions and to express sympathy. Now that the first shock has subsided it may have become clearer to you what your needs are to try to overcome the tsunami, and to compensate for associated losses.
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I’ve been struck by the rich discussions about physician migration at FAIMER Board meetings. In our own institution in New Mexico, I have reviewed the post-graduate residents we have trained in Family Medicine, with the intent that they would return to their home countries and develop their own Family Medicine programmes. None have returned. Yet of the ECFMG fellows that are mid-career and spend 6-12 months with us, ALL have returned to their own countries and all have assumed leadership positions. Thus, I feel this informal organisational partnership will bring mutual benefits to The Network: TUFH and to FAIMER.
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These are all areas of interest to The Network: TUFH, particularly FAIMER’s unique strengths regarding its extensive tracking abilities, research capacity and leadership development focus. The leaders of ECFMG/FAIMER have made a decision to increase their partnership with likeminded organisations, so they have attended the last two Network: TUFH annual Conferences, in Australia and the US. Through contacts between our two organisations at these meetings, ideas of collaboration have been percolating, such as sharing information, meetings, and publications on each other’s websites, and inviting FAIMER Fellows to submit their innovative work to The Network: TUFH journal, Education for Health. In fact, two leaders within FAIMER, Dr. Bill Burdick, Co-Director of the FAIMER Institute and Dr. Jack Boulet,
HELPING HAND Dear Network: TUFH member or affiliate,
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FAIMER’s activities are concentrated in three areas: tracking medical education world-wide, building and sharing their database with interested students, faculty, academic centres and organisations; educating educators - offering faculty development and leadership development programmes for mid-career faculty in developing countries, leading to their becoming local leaders in education reform aimed at improving health outcomes; discovering disseminating knowledge - exploring critical topics like understanding the causes of and impact of physician migration or understanding the link between innovative education and health outcomes.
Director of Research have joined the Editorial Board of Education for Health.
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THE NETWORK: TUFH IN ACTION ANNUAL INTERNATIONAL CONFERENCE Every year The Network: TUFH organises an international scientific and networking conference. This year the Conference will be held in Ho Chi Minh City, Vietnam, from 12 - 17 November (co-hosted by the University of Medicine and Pharmacy in Ho Chi Minh City) and will be followed by a post-Conference excursion in Can Tho, Vietnam, from 18 - 20 November (co-hosted by the Can Tho University of Medicine and Pharmacy).
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‘South-North’: Collaboration Nepal - Netherlands
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In 1994, a very young B.P. Koirala Institute of Health Sciences (BPKIHS) wanted to establish national and international relationships in order to boost its new and relatively innovative medical education approach. Several individuals, including Charles Boelen, Samlee Plianbangchang, Palitha Abeykoon, P.T. Jayawickramarajah (educationalists of the WHO), and Abraham Joseph (Christian Medical College, Vellore, India) were instrumental in the process of internationalisation of the institute. BPKIHS became a member of The Network: TUFH in 1997. Through The Network: TUFH, Maastricht Faculty of Medicine came into contact with BPKIHS, and in 1999 a group of Maastricht students visited BPKIHS for their electives. Since then every year Maastricht students come to BPKIHS. So far 24 students have completed their electives and 18 their clerkships. BPKIHS offers them clerkships in Ophthalmology, Surgery and Gynaecology & Obstetrics. The educational approach and the community setups for learning are attractive to many international students. One who wonders what community-based and community-oriented education means in a practical sense, could visit BPKIHS and feel the sentiments embedded into these approaches of learning. BPKIHS offers elective postings and clinical clerkships in all Departments. Residential postings in community health facilities in the hills and plains offer exciting experiences to the students in respect to understanding different cultures, people, and health practices. Though learning is the student’s main concern, they cannot remain untouched with the beauty of the countryside.
Nepalese and Dutch students on rounds BPKIHS also participates regularly in Maastricht activities. The programme best liked by the Nepalese faculty members is the annual Summer Course Expanding Horizons in Problem-Based Learning in Medicine, Health and Behavioural Sciences. Personally, I experienced Maastricht Faculty of Medicine as a true international centre for health professions education. The dedication of the teaching faculty and staff in bringing innovations into the learning process is tremendous. In the meantime, BPKIHS has become a Full Member of The Network: TUFH. Participation in The Network: TUFH Conferences has brought BPKIHS closer to many communityoriented medical schools around the world. Listing the name of BPKIHS, Dharan as one of the centres to organise a future Network: TUFH Conference has encouraged us to work more closely. We are hoping that day will come soon. Akshaya Gautam | Academic Supervisor, B.P. Koirala Institute of Health Sciences, Nepal Email: akshayagautam@yahoo.com
In October 2004 Maarten Visschers - 4th year student at Maastricht Faculty of Medicine - went to B.P. Koirala Institute of Health Sciences in Dharan for an eightweek clerkship Surgery: “I was the first Maastricht Medical student to do a Surgery clerkship in Dharan, you could say I was a pioneer. When I arrived at BPKIHS the clerkship programme was completely new and therefore still had some ‘teething troubles’. But those have been addressed, and now Maastricht students can have a wonderful clerkship in Dharan - including good supervision of the Nepalese doctors - provided that the student enters into the clerkship with a positive and pro-active attitude. You can join as many medical interventions as you want, as long as you ask for it. I requested a one-week clerkship in a regional hospital in Dhankuta (a two-hours drive from Dharan), and I’m glad I did: I had an impressive and informative experience in Nepalese district healthcare. Especially the poignant cases - like patients who died because they could not afford the € 22 treatment - had a deep impact on me.
I HAD AN IMPRESSIVE AND INFORMATIVE EXPERIENCE IN NEPALESE DISTRICT HEALTHCARE. Not only is the healthcare system in Nepal different, the staff and students also dif-
YOU CAN JOIN AS MANY MEDICAL INTERVENTIONS AS YOU WANT, AS LONG AS YOU ASK FOR IT.
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Abstract submission (for Mini-workshops or Thematic Poster Sessions): www.the-networktufh.org/conference/ abstractchoice.asp Abstracts can be submitted until August 1, 2005.
The exhibitor/co-sponsor application, available at www.the-networktufh.org/ conference/default.asp?id=18&aid=18 presents a range of options for co-sponsoring the Conference, for hosting an exhibit table, or contributing to a literature table. If you don’t see an option that meets your needs, please let us know!
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Registration: www.the-networktufh.org/conference/ registration.asp www.the-networktufh.org/conference/ registrationform.asp Registrations will be accepted until the end of October 2005. Please note that the deadline for early registration is August 1, 2005.
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Preliminary programme: www.the-networktufh.org/conference/ programme.asp
To maximise exposure for all exhibitors and co-sponsors, the Conference will feature a gala reception. This will include hors d’oeuvres and an incentive activity to encourage attendees to visit each of our exhibitors. We have also procured space for the exhibit area near session rooms and central ballrooms.
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Conference site: www.the-networktufh.org/conference/
Over 300 health leaders from academic, clinical, and community settings from over 45 countries around the globe are expected to attend the Conference. You can increase exposure to your programmes, products and services by being an exhibitor and/or co-sponsor. In addition to connecting participants with valuable resources for improving health, your support enables community-based leaders and students to attend by offsetting travel and registration expenses.
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My clerkship at BPKIHS was absolutely worthwhile; I had plenty of practical experience (sometimes I even participated in operations that you are not allowed to do in the Netherlands) and saw a completely different (healthcare) world than mine.”
After the Conference there will be an optional excursion to the University of Medicine and Pharmacy, Can Tho, Vietnam (November 18 - 20, 2005). The theme of the excursion is Community-Based Health Professions Education.
The Network: TUFH invites your organisation to participate as an exhibitor or co-sponsor of the 2005 Conference in Vietnam.
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fer from Maastricht staff and students. For example, Nepalese students have more medical knowledge than their Dutch peers, so it is wise for Maastricht students to use the first weeks of their clerkship to catch up by studying basic knowledge. Also the relationship between students and staff is very different than in the Netherlands; where we are very loose with our supervisors (sometimes even call them with their first names), in Nepal there is a strong hierarchy and you always address your superior with Sir or Madam.
The 2005 Conference In November 2005 The Network: TUFH will organise its annual Conference in collaboration with the University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam. This Conference will be held in Ho Chi Minh City, Vietnam, November 12 – 17, 2005. The theme of the Conference is Making Primary Health Care Work: Challenges for the Education and Practice of the Health Workforce.
Participate as an Exhibitor and/or Co-Sponsor
If you have any questions, or would like to register as an exhibitor and/or cosponsor, please contact Piper Krauel at piper@thecenter.ucsf.edu
Having a traditional Nepalese drink (Tongba) with fellow students
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THE NETWORK: TUFH IN ACTION POSITION PAPER The Network: TUFH Executive Committee decided to undertake the writing of a series of ‘Position Papers’ on issues that are closely related to the aims and objectives of our organisation. They must be seen as starting points for further discussion. You may contribute by submitting a letter to secretariat@network.unimaas.nl, by participating in sessions on these issues at Network: TUFH Conferences, or responding to the electronic versions of these Position Papers at the Network: TUFH’s Internet site (www.the-networktufh.org/publications_resources/positionpapers.asp).
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Integrating Medicine and Public Health
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Introduction Medicine and public health are considered two different disciplines, the former being focused on individual patient care and consultation, the latter on population-oriented issues. In addition, medicine primarily addresses the diagnosis and treatment of diseases; public health primarily addresses promotion and prevention. Historically, the differences were not only based on the professional perspective and skills, but also on the institutional and social environment in which they were applied. Medicine is mainly concerned with the physical health of the patient; public health addresses the health of populations and its behavioural, social and economical determinants (Gruskin & Tarantola, 2002). Health professionals in different parts of the world prefer to express the divide as ‘individual care and public health’. This is not a semantic difference, as the distinction reflects different points of view of the health professions (as ‘medicine’ may be considered the work of the physicians only) and also the particular characteristics of the health worker functions and of the country healthcare system. Today, the organisation of health services is fragmented, as demonstrated by the division between individual healthcare and community health services; biomedical and psychosocial models; curative and preventive care; services provided by generalists and specialists; public and private sectors. In this respect the emphasis on biological mechanisms diverts attention from the behavioural, social, economic, cultural and
environmental conditions and there is also growing imbalance in the availability and use of resources in both individual healthcare and community health services. As another result of the fragmentation of services, there is growing disparity in terms of the delivery of health services among different groups in the population, among the indigenous communities, people in the slums, among the poorest sector of the society and children with special needs (child labour, child traffic, child soldiers). As the divide between medicine and public health is expressed mainly at the primary care level, it is habitual for medicine and primary medical care to be taken as synonymous. It is important to emphasize the differences between primary medical care and primary healthcare, the latter being a more comprehensive approach to health and healthcare. In the USA, specialty care is often regarded as the epitome of medicine, and some regard primary care as more closely related to public health, especially since primary care providers may offer prevention and community-based services. The on-going debate, of an ideological and organisational nature, may help to narrow the gap between medicine/individual healthcare and public health, particularly where professionals and organisations agree to recommend a community orientation of primary care. Furthermore, as the separation may also be due to the traditional defined framework of each discipline, Heller (Heller et al., 2003) claims that there is a need to re-define
Dr. Jaime Gofin public health, because of the absence in the classical definitions, of precise understanding of the public, as in contrast to the individual health components. He proposes a new definition of public health as the “use of theory, experience and evidence derived through the population sciences to improve health of the population, in a way that best meets the implicit and explicit needs of the community (the public)”. This definition gives emphasis to the ‘public’ in a way that might be clearer to people who are not public health practitioners. Although there are questions on ‘What’s new about the ‘New Public Health’’ (Awofeso, 2004), the components of ‘Health Promotion such as Health Education, Prevention and Protection’, may have a role towards integration and in that way should be considered. The defined framework of the public health discipline has been dealt with by the WHO International Study (Bettcher et al., 1998) regarding the formulation of Essential Public Health Functions (EPHF), and by the US Department of Health and Health Services (Public Health Functions Steering Committee, 1995) which developed the 10 EPHF. Both include functions that are covered by individual healthcare. Individual healthcare could be considered as part of public health functions when they are able to produce population-wide benefits (Bettcher et al., 1998). The Meaning of Integration To avoid misunderstandings and misconceptions it is necessary to pay attention to
different meanings given to integrated care and therefore to integration. Integration is a multidimensional concept that reminds us that the word comes from Latin integer, that is ‘to complete’; integrated means ‘organic parts of a whole’, or ‘reunited parts of a whole’ (Kodner & Spreeuwenberg, 2002) and according to the Webster Dictionary it is ‘the act or instance of combining into an integral whole’.
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As an illustration of an integrative approach Community-Oriented Primary Care (COPC), which integrates primary care and community medicine, takes responsibility for a defined population, by an assessment of its health needs, setting priorities and planning and implementing programmes to address the identified needs (Kark, 1981; Epstein, 2002). In that respect COPC is considered as public health at local level.
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• The need to have and implement approaches to integrate primary care and public health. Lasker (Lasker, 1997) states that in spite of the fact that the separation between these two fields related to medical practice had remained “as it was in the late 1970s, there are today reasons to re-evaluate their relationship”. Not only to recognise that the two sectors are under economic and performance pressure, but also to realise that neither of them can accomplish their mission alone.
In Sri Lanka the integration of family planning and related services of maternal health in the PHC services (Fernando et al., 2003) based in several strategies that were implemented within and outside the health sector, determined an important decrease in maternal mortality. The integration of Leprosy Services in the PHC system of Sri Lanka required improvement in logistics, promoting changes of attitudes, training of health workers and support by an intensive advertising campaign to inform the population; this integration determined a more efficient process of diagnosis, treatment and management of the disease (Kasturiaratchi et al., 2002). In Costa Rica, the development of the National Health Care System with reforms of the healthcare infrastructure and strengthening of the PHC services included approaches of integrated care for the population (Bertodano, 2003). The reforms counted with a political will to support the approach (Barrett, 1996) and resulted in the improvement of health conditions in the country. Still there is a need for further research on effectiveness, as commented on studies that show that integrated structures (Reilly et al., 2003) are associated more with inte-
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The Search for Appropriate Approaches for Integration We suggest an examination of three dimensions in order to deal with the possible alternatives of integration:
• The effectiveness of the proposed approaches. There is evidence that by integrating primary care with public health in diverse socio-economic situations and health services systems, there is a positive impact on the health of people (Hart et al., 1993; Abramson, 1988; Harvey, 2001; Longlett et al., 2000; American Journal of Public Health, 2002; Illife & Lenihan, 2003).
Approaches like those of Medicine Public Health Initiative (Cashman et al., 1999), Planned Approach to Community Health (PATCH) (Planned Approach to Community Health, 2004), Healthy Communities (Cashman & Stenger, 2003), and Community-Campus Partnership for Health (CCPH) (Community-Campus Partnership for Health, 2004) could be important facilitators and protagonists in the different versions of integration, given their targets and their national scope in the USA.
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Above all, it is necessary to assess that “Integration is ‘real’ (and) not merely a convenient shorthand term to describe a class of programmes” (Cronbach, 1989, cited in ref.7).
Another expression of the need of narrowing the gap comes from the experience in the relation between health and humans rights as mentioned at the PH Textbook 2002, “...as the human rights approach has made increasingly clear, this stark differentiation between medicine and public health is not longer fully relevant either to human rights or to health” (Gruskin & Tarantola, 2002).
Also the Primary Health Care (PHC) approach incorporates curative and rehabilitative actions (clinical care) and promotive and preventive actions (public health).
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Questions arise on whether this integration refers to healthcare with social care or whether it is the integration of different levels of care, or whether it is an activity, a process, or a structure. Batterham et al. (Batterham et al., 2002) point out that integration could be conceptualised as a process (of the two related concepts of patient care and public health integration) with an integration structure.
In the present situation the medicine perspective gives “great weight to biologism and medicalisation” (Pan American Health Organization, 1993), there is lack of consideration of the socio-economic and political causes of the ill-health process (Werner & Sanders, 1997), and there is a lack of coordination when the two disciplines are dealing with the same population. All these realities have negative effects on health and on healthcare services, and lead to deterioration in “productivity of health services and a loss of quality, rise in costs and inequities” (Boelen, 2000).
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THE NETWORK: TUFH IN ACTION POSITION PAPER
gration of management but less with ‘integrated practice-related services’.
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• The feasibility to integrate both fields. This dimension should be analysed by an assessment of two complementary aspects: whether there are models that are explicitly oriented to the integration and second, experience with interventions that have already been implemented.
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With respect to the first aspect, Lasker (Lasker, 1997) describes four ‘movements’ to relate individual patient care to a broader socio-physical environmental: social medicine, COPC, preventive medicine and initiatives to increase population perspective in medical education. While the latter implies a necessary longterm investment, there is an extensive literature on the other three ‘movements’ that have already been implemented and provide information on the feasibility of their interventions. In the developing countries primary healthcare also constitutes a movement with an extended experience and application. The feasibility probe needs to take into account resources (financial, personnel, facilities), conformity with health policy (local, regional, national), attitudes of health team members (interest, motivation, co-operation), and cultural milieu (citizen/ society relationship, democratic spirit) (Barrett, 1996). Epidemiology as a Key Element in the Integration It is also important to relate to the central function of epidemiology in the analysis of separation or integration of the two fields of practice. Although before the 1900s, clinical medicine and public health interventions were related, the changes (evolution) in both disciplines after that period, determined that epidemiology ‘moved’ to
public health, and the teaching in epidemiology became part of the Schools of PH. This exit from the Medical Schools was one of the main causes of the gap between medicine and public health. In the second part of the 20th Century, when the emphasis on epidemiology shifted from the macro to the microenvironment, with the study of personal characteristics and habits, it returned to a renewed relationship with the clinical professions. Moreover the development of clinical epidemiology and molecular epidemiology tended to bring issues of public health closer to clinical medicine (Adami & Trichopoulos, 1999). An illustration of the role of epidemiology in the integration of medicine and public health is in the complementary use of epidemiological and clinical skills in primary care. General Practitioners and Family Physicians are frontline gatherers of information about the health needs of their patients, their families and their community. Epidemiological methods and expertise, help to the clinical professionals to achieve a broader identification of the health needs at population level and in that way to an appropriate assessment of the effectiveness of alternative interventions to implement in their communities. Because often the physicians apply their findings only to the individual patient, this gap could be narrowed by integration of clinical medicine and public health. Ibrahim points out the increasing awareness by integrated medical delivery systems and managed care organisations, of the value of population-based health principles in medical and public health practice. The principles relevant to an integrative approach are: a community perspective, a clinical epidemiology perspective, evidence-based practice, an emphasis on outcomes and an emphasis on prevention (Ibrahim, 2001). The implementation of these principles requires the organ-
isation of a Management Information System, for which professionals involved in the integration need to acquire the necessary skills, or to receive an easy access to an appropriate expertise support. The isolated use of epidemiological methods by integrated medical systems to assess quality of care provided to patients does not mean an integration of medicine and public health. Why Does the Separation in the Health Services Still Prevail? Although the medical and health literature offer designs, comments and advocacy for the different models of integration, there is not a wide adoption of these models. The reasons for this limited application might be related to the lack of relevance of the diverse approaches: to local policy, to local conditions and resources, to professional attitudes, and to community perceptions. The identification and analysis of these constraints should help in reducing them, and in the channelling of delivery of care towards a more rational organisation. • Constraints due to health policy reasons The lack of agreement with health policy, with the decision-making process, with specific decisions taken by health authorities, may create difficulties in the re-orientation: - decisions taken from the top-down instead from the bottom up, - introduction of accountability without appropriate consultation and prior preparation for the change can constitute a new threat for organisations and for individual professionals, - priority setting as a requirement at the institution level for the changes in service patterns, which may result in postponement with a subsequent disturbance of other activities, - separated funding streams, for public health and medical services,
- separated entrenched bureaucracies for public health and medical services.
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The marked difference between type and amount of resources available in each field creates animosity among practitioners of both branches while the required resources for the integration may not be a simple addition of what is available. Time required for re-orientation of health services in already overloaded practices (the demand!) is a formidable hindrance in the planning and implementation process.
The integration needs to take into account the perception of professionals who see this process as a continuum, in which the extremes are distinct as disciplines, from individual care to responsibility for public health, but “...the rest of the continuum is inextricable” (Parsons et al., 1993).
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A new approach is a re-orientation that demands extra funding in an already constrained budget, and although in the long run the change becomes more manageable, initially presents a difficult challenge.
An important factor in professional attitudes relates to remuneration, where feefor-services constitutes an obstacle to integration. Incentives could be a very useful element in changing attitudes.
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One of the health policies that affect the integration in the Asian Region is the decentralisation of health services. The
Studies on the changes in the NHS in the UK are revealing the contractual, organisational and financial difficulties manifested by the professionals with regard to the reforms related to integration (Cornell, 1999).
The difficulty in converting to a pro-active attitude in a health practice after having been trained and practiced in a re-active mode, and the difficulty in setting priorities at the health team level on the order of urgency in addressing health needs, might slow down the adoption of the integrative approach. When public health professionals undertake a Health Needs Assessment (HNA) as an end, and not as a means towards meeting those needs by an appropriate intervention, it constitutes an obstacle to the integration.
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In an assessment of the policy of the NHS, an editorial in the British Medical Journal (Hannay, 1993) notes “PC and PH being too apart”, while an editorial in the Journal of Epidemiology and Community Health (Bhopal, 1995) points out that PC and PH need to converge but warns that “...this goal will be achieved with difficulty”.
• Constraints due to lack of resources and/or to economic/financial reasons Although there have been changes in West African countries in the academic curriculum with the inclusion of community medicine and public health in medical studies, in the practice it is very difficult to apply integration due to the lack of human resources (e.g. one physician for 20,000 80,000 inhabitants).
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In the reform process undertaken by a new health policy at the National Health Services (NHS) at the national level in the UK, Ashton (Ashton, 1990) considered four caveats as the obstacles in the integration of the whole of “public health to be subsumed under primary health care (PHC)”: - a narrow view of health promotion by PHC, - staff in PHC would not be motivated to PH work, - some tasks could not be done at PHC (e.g. health strategy), - the need to reconcile the conflict between individual and collective health, may require separation of the roles of advocate, mediator and enabler.
The impact of educational innovations integrating the teaching of clinical medicine and public health are blunted when there is not a comparable health policy of service innovation.
• Constraints due to professional attitudes and training Health professionals of the two fields of practice have pursued different career pathways, with primary care practitioners having had little training in skills of population health, and public health doctors and nurses being far away from the day to day overloaded patient consultations, practices in which new responsibilities are added, such as health promotion and prevention. The reluctance to change that might be present in professionals of both fields may also have a role in the barriers to adopt an integration approach.
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There may also be tensions between the policy of primary care and public health, as seen in the new forms of organisations in the personal health services in the USA. These services are claiming an orientation toward primary care assuming responsibility for the care of populations, and in this way they are “creating strains in...the linkage between the two sectors”. It is pointed out that managed care also “poses a threat to...public health” (Starfield, 1996) by focusing on enrolled populations and in prevention activities.
communities and towns that have adequate and extra resources tend to be innovative in meeting the needs of the population while in communities and towns that are poor in resources, the interventions are limited and usually they have scarce health supplies.
In addition, training programmes both in public health and in medicine need to be re-tooled, if graduates are to be prepared to practice in an integrated system. 9
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• The community’s perceptions ad priorities The community perception about the professional role in personal care, to prescribe and to answer to the individual’s demand (‘medical role’) prevailing over public health counselling (‘promotion role’), may influence their perspectives towards integration. The very close relationship between the individual and his personal medical doctor creates links and opinions that are quite different from the connection with anonymous professionals in the ‘distant’ public health services.
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Most individuals perceive their own health needs in terms of treatment of symptoms or disease. This is the service provided by clinical medicine, and the personal physician who provides this service is the healthcare professional recognised by most persons. While the separate public health department or public health programmes provide an important service, it is often not recognised or appreciated by the community. The public may therefore not recognise the value of integration of public health and medicine. What Are the Conditions to Create Integration? Although integration may have diverse expression according to specific local healthcare systems of different countries, there are five conditions that should be considered as indispensable to create integration [modified from Boelen C (ref. 6)]: • common set of values (quality, equity, relevance, and cost-effectiveness), • common population concern, • shared health information system, • organisational approach to integrate interventions, • partnership with stakeholders.
Role of the ‘Stakeholders’ Proposals for integration require the active involvement of disciplines, institutions and sectors, not only that of the medical sector alone! It is been suggested that this involvement for integration should be a partnership among five stakeholders: • policy makers, • health managers, • health professionals, • academic institutions, • communities. Each one of the stakeholders would need to have a defined role in the development of the integration. • Role of policy makers Whether integration could be implemented at local, regional or national level, health policy is necessary to enforce a sustainable re-orientation of health services. The relation between health policy and politicians should be directed to answer the increasing demand for rational organisation of delivery of healthcare. The allocation of resources is very much dependent on explicit health policy; in that case the policy could be a catalyst force to be considered and followed by the other stakeholders. To promote integration may relate not only to the health systems reforms but also with the need to reach consensus to develop “strategies and plans to promote greater integration of healthcare delivery”, as expressed (Bergman & Beland, 2002) in the current discussion on healthcare in Canada. • Role of health managers Managers are responsible for organising, financing and management of health services (health organisations, insurance plans). Since the main concern for health managers at an institutional level might be
the coverage of their care and the cost-effectiveness of the services they provide, the proposal of an integrated service should be based on rational and accountable systems. • Role of health professionals Because health professionals are made up of a number of disciplines with specific skills and responsibilities, their roles should be formally established to become essential partners in the integration. While clinical professionals have been trained with a focus on curative medicine and on tertiary care, an integrated system would require them to perform activities related to the disciplines and activities of public health. In this respect the motivation of the professionals becomes an important element in the acquisition of relevant skills. Changes have been observed in the attitudes of the organisations of professionals as shown by the WONCA (WONCA Durban Declaration, 2004) Durban Declaration, on the need for Family Physicians to extend their field of action from the individual and the family, also to the community. In addition, the publication of the WONCA Guidebook on Improving Health Systems: the Contribution of Family Medicine, analyses the different roles of family medicine in the implementation of primary health care, which features elements needed in the integration of primary care and public health (Boelen et al., 2002). It is worth mentioning that there are two different streams among Family Physicians, those who give emphasis to the clinical and communication skills as the central issue of their contribution to primary care, and those who emphasize that family medicine should extend its field of action towards community medicine (Foz et al., 2003). Family Physicians could fulfil leadership roles in working towards integration between medicine and public health. The involvement of other health professionals
public health) (Gofin, 2002; Waterstone & Sanders, 1987). The social accountability of academic institutions requires a commitment that must be reflected not only on a ‘different’ location of training (more ‘community-based’) but also providing students with learning experiences to recognise the population’s health needs. This practice will determine better understanding of the ill-health process at community level, might create a sense of ‘belonging’ to the community (Gofin, 2002) and create appropriate attitudes towards integration among graduates.
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The Child Centred Community Development (CCCD) (in the Asian Region) has been endorsed as the programme approach in Plan International. Children health clubs have been important groups in the com-
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The teaching of community medicine can be considered as a means for addressing the fragmentation of services, and therefore should be part of the training of health sciences professionals (medical, nursing,
Role of The Network: Towards Unity for Health Considering the reality described above, the main questions should be: • who is actively taking care of the people’s health needs? • are there approaches that promote the health of the public more effectively than the option of technical coordination of primary care and public health?
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However, institutions and professional stakeholders hold considerable power in the society while communities, especially in the impoverished areas, hold little. This imbalance of power is in itself an important source of ill health and disparities in health in different societies, and therefore the integration of medicine and public health must consider a greater participatory role of the community in health and health related interventions.
In the search of feasible integrated approaches, there is an essential need by the integrated organisation to have an appropriate budget to purchase, for example, the health services related to its population needs. It is also important to consider that the integration at local/regional level or by providers at national level is ‘almost impossible’ without the political support of the medical services and public health authorities.
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The development of the Network of Community-Oriented Educational Institutions for Health Sciences (today The Network: TUFH) including Schools of Medicine all over the world, provides an essential bridge towards the integration of health services. Students, from the very beginning of their studies should be made aware of people’s health needs in their communities, and learn about the processes for dealing with those needs.
The Five Stakeholders Commitment Proposals for integration among the five stakeholders should consider the opportunities and the constraining factors in the forging of the partnership, not only for an increase of communication, but also for an appropriate commitment of each one of them, from ad-hoc arrangements to long term commitments.
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The educational strategy for integration might be the one that assures a cultural change and in that sense pre-graduate education is of crucial relevance.
• Role of communities In an integrated approach, the community is not a consumer but a partner, with rights and responsibilities. In that sense, the other four stakeholders need to be accountable to the community by consulting the community members for suggestions, priorities and special needs. On the other hand, the community must acquire a suitable organisation to serve in facilitating its partnership in the whole process, in protecting its rights, and ensuring an active involvement in all relevant collaborative activities with the health services.
• Role of academic institutions Academic institutions, because of their wide spectrum of functions in education, research and services delivery, have the potential to understand and address complex issues related to the process of integration of health services. Academic leaders should also review their prejudice against changes on the traditional teaching programmes.
munity to facilitate and promote public health activities and even the practice of medicine through child-to-child scheme, with school authorities and parents support. The social accountability of the four stakeholders is not only in regard to provision of services, but also regarding the socio-economic determinants of health. Community members should be included as participants in health activities, while exploring their participation in decisionmaking. In this respect, the integrative approach should include an active intersectorial coordination. J U N E
in the integration of medicine and public health are of paramount importance. Nurses who have close relationships with patients and with other people in the community, have an important role in narrowing the gap between individual and community care (Kark, 1981). The involvement of health visitors, district nurses, school nurses and practical nurses in a healthneeds assessment process in a primary care setting in Manchester (Horne & Costello, 2003), is another example of integration, as an interface between primary care and community development through a public health approach.
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• how should the integration deal with inequalities in health and health determinants take into account human rights? There is a rich global experience in the community orientation of medical studies, led by The Network (as its previous name indicates: Network of Community-Oriented Educational Institutions for Health Sciences). The 12 field projects underway world-wide by TUFH, at the local and regional level, are new patterns of services for integration, with a sustainable partnership among the stakeholders of the health sector. The amalgamation of both organisations creates a new reality in the development of the necessary partnerships for an integration of medicine and public health. By the creation of the taskforce on Medicine and Public Health, The Network: TUFH takes the responsibility to share with other similar ‘movements’, its contribution in leading the integration on a global basis. No specific approach could be suggested, since the aim of the taskforce is to promote the principles of integration with their universal value, while the implementation will depend on the local reality. To promote and incorporate the values of quality, equity, relevance, and cost-effectiveness (Boelen, 2000) it is necessary to consolidate a base derived from scientific knowledge, practical experience and firm convictions and to consider the relationship with the social, economic, and political sectors of society. For the fulfilment of this role, an essential requirement is coordination with all the people who - at individual and institutional level - are already committed to the improvement of the population’s health.
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References ABRAHAMSON, J.H. (1988). Communityoriented primary care - strategy, approaches, and practice: a review. Public Health Review, 16, 35-98. ADAMI, H.O. & TRICHOPOULOS, D. (1999). Epidemiology, medicine and public health. International Journal Epidemiology, 28, S1005-S1088. AMERICAN JOURNAL OF PUBLIC HEALTH, vol. 92 (11) November 2002; eight articles on Community-Oriented Primary Care (COPC). ASHTON, J. (1990). Public health and primary care: Towards a common agenda. Public Health, 104, 387-398. AWOFESO, N. (2004). What’s new about the “New Public Health”. American Journal of Public Health, 94:705-709. BARRETT B. (1996). Integrated local health systems in Central America. Social Science Medical, 43(1), 71-82. BATTTERHAM, T., SOUTHERN, D., APPLEBY, N., ELSWORTH, G., FABRIS, S., DUNT, D. & YOUNG, D. (2002). Construction of a GP integration model. Social Sciences Medicine, 54, 1225-1241. BERGMAN, H. & BELAND, F. (2002). Commentary on: The future of health care in Canada. International Journal of Integrated Care. Available at www.ijic.org/ publish/articles/000086/ BERTODANO I. (2003). The Costa Rican health system: Low cost, high value. Bull World Health Organization, 81(8), 626627. BETTCHER, D.W., SAPIRIE, S. & GOON, E. (1998). Essential public health functions: Results of the international Delphi study. World Health Statistics, 51, 44-54. BHOPAL, R. (1995). Public health medicine and primary health care: convergent, divergent, or parallel paths? Journal of Epidemiology and Community Health, 49, 113-116.
BOELEN, C. (2000). Towards Unity for Health: Challenges and opportunities for partnership in health development. A working paper. Geneva, World Health Organization. BOELEN, C., HAQ, C., HUNT, V., RIVO, M. & SHAHADY, E. (2002). Improving health systems: The contribution of family medicine - A guidebook. World Organization of Family Doctors (WONCA). Singapore: Bestprint Printing Company. CASHMAN, S.B., ANDERSON, R.J., WEISBUCH, J.B., SCHWARZ & FULMER, H.S. (1999). Carrying out the medicine/public health initiative: The roles of preventive medicine and community-responsive care. Academic Medicine, 74, 473-483. CASHMAN, S.B. & STENGER, J. (2003). Healthy communities: A natural ally for community-oriented primary care. American Journal Public Health, 93, 1379. Community-Campus Partnership for Health (Accessed February 3, 2004) Available at: www.futurehealth.ucsf.edu/ccph.html CORNELL, S.J. (1999). Public health and primary care collaboration – A case study. Journal of Public Health Medicine, 21 (2), 199-204. EPSTEIN, L., GOFIN, J., GOFIN, R. & NEUMARK, Y. (2002). The Jerusalem experience: Three decades of service, research, and training in community-oriented primary care. American Journal of Public Health, 92, 1717-1721. FERNANDO, D., JAYATILLEKA, A. & KARUNARATNA, V. (2003). Pregnancy – reducing maternal deaths and disability in Sri Lanka: national strategies. British Medical Bulletin, 67, 85-98. FOZ, G., GOFIN, J. & MONTANER GOMIS, I. (2003). Atencion primaria orientada a la communidad. Cap. 20. In: A. MARTIN ZURRO & J.F. CANO PEREZ (Eds.), Atencion primaria – Conceptos, organizacion y practica clinica, 5th Ed. Barcelona: Elsevier.
WATERSTONE, T. & SANDERS, D. (1987). Primary health care teaching: Some lessons from Zimbabwe. Medical Education, 21, 4-9. WERNER, D. & SANDERS, D. (1997). Questioning the solution: The politics of primary care and child survival. Palo Alto CA, California Health Rights, Workgroup for People’s Health and Rights. WONCA Durban Declaration (Accessed February 8th, 2004). Available at: www.rudasa.org.za/download/durbadec.pdf. This Position Paper is also available at www.the-networktufh.org/publications_ resources/positionpapers.asp
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Translations: • Spanish translation of Integrating Primary Healthcare with Public Health • Spanish translation of Primary Care • Portuguese translation of ProblemBased Learning • Greek translation of Problem-Based Learning
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AN OVERVIEW OF THE POSITION PAPERS • Community-Based Education for Health Professionals • Integrating Medicine and Public Health • Integrating Primary Healthcare with Public Health • Multiprofessional Education & Addendum • Primary Care • Problem-Based Learning • The Need for Research in Primary Care to Solve Global Health Problems
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Jaime Gofin | Corresponding author on behalf of the writing group Email: jaime@md2.huji.ac.il
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KASTURIARATCHI, N.D., SETTINAYAKE, S. & GREWAL, P. (2002). Processes and challenges: How the Sri Lankan health system managed the integration of leprosy services. Lepr Rev., 73(2), 177- 185. KODNER, D.L. & SPREEUWENBERG, C. (2002). Integrated care: Meaning, logic, applications, and implications – a discussion paper. International Journal Integrated Care. Available at www.ijic.org/ publish/articles/000089 LASKER, R.D. (1997). Medicine and public health – The power of collaboration, Part I: The collaborative imperative. New York: New York Academy of Medicine. LONGLETT, S.K., KRUSE, J.E. & WESLEY, R.M. (2000). Community-oriented primary care: Critical assessment and implications for residents education. Journal American Board Family Practitioners, 14, 141-147. PAN AMERICAN HEALTH ORGANIZATION (1993). On the theory and practice of public health: One debate, several perspectives. Washington D.C., Pan American Health Organization. PARSONS, L. et al. (1993). Primary care and public health - Differing roles create tensions (letter). British Medical Journal, 307, 1144. PATCH: Planned Approach to Community Health (Accessed January 27, 2004). Available at: www.cdc.gov/nccdphp/patch. PUBLIC HEALTH FUNCTIONS STEERING COMMITTEE (1995). Public health in America. Washington D.C., Department of Health and Human Services. Available at www.health.gov/phfunctions/public.htm REILLY, S., CHALLIS, D., BURNS, A. & HUGHES, J. (2003). Does integration really make a difference? A comparison of old age psychiatry services in England and Northern Ireland. International Journal Geriatric Psychiatry, 18, 887-893. STARFIELD, B. (1996). Public health and primary care: A framework for proposed linkages; American Journal Public Health, 86 (10), 1365-1369.
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GOFIN, J. (2002). Planning the teaching of community health (COPC) in an MPH program. Public Health Reviews, 30, 293301. GRUSKIN, S. & TARANTOLA, D. (2002). Health and human rights. In: R. DETELS, J. MCEWEN, R. BEAGHEHOLE & H. TANAKA (Eds.), Oxford textbook of public health, 4th Ed. New York: Oxford University Press. HANNAY, D.R. (1993). Primary care and public health - Too far apart. British Medical Journal, 307, 516- 517. HART, T. et al. (1993). Twenty-five years of audited screening in a socially deprived community. British Medical Journal, 302, 1509- 1513. HARVEY, P. (2001). The impact of coordinated care: Eyre Region South Australia 1997-1999. Australian Journal of Rural Health, 9(2), 69- 73. HELLER, R.F., HELLER, T.D. & PATTISON S. (2003). Putting the public back into public health. Part I. A re-definition of public health. Public Health, 117 (1), 62-65. HORNE, M. & COSTELLO, J. (2003). A public health approach to health needs assessment at the interface of primary care and community development: Findings from an action research study. Primary Health Care Research and Development, 4, 340352. IBRAHIM, M.A., SAVITZ, L.A., CAREY, T.S. & WAGNER, E.H. (2001). Population-based health principles in medical and public health practice. Journal Public Health Management & Practice, 7(3), 75- 81. ILLIFE, S & LENIHAN, P. (2003). Integrating primary care and public health: Learning from the community-oriented primary care model. International Journal Health Services, 33(1), 85-98. KARK, S.L. (1981). The practice of community-oriented primary care. New York NY: Appleton-Century-Crofts.
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Review Position Paper on Primary Care: Revolution Starts With the Middle Class
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This review must be seen in the context of the challenge to deliver equitable healthcare in a world ruled largely by global capitalism, a world where power, status and profit are entrenched in healthcare. It is important to read this Position Paper on Primary Care and other Network: TUFH Position Papers. These documents grow from action, experience and evidence. They provide crucial guidance and information to primary care academics, especially those who are passionate about the social responsiveness of their institutions. A list of resources, provided by some of the other Position Papers, would make this one even more useful. The Position Paper on Primary Care gives the rationale for increasing primary care as a valued specialty in academic health institutions, and it explains how this goal can be achieved. Networking and community involvement are crucial elements. The definitions, developments and examples communicate important principles and illustrate how implementation can be done in different contexts. Examples of advances through collaboration between institutions and countries are absent. These would provide evidence for the value of networking, and would encourage academics to develop joint projects. Contact details of institutions and individuals interested in collaboration will enable beginners and strugglers to collaborate. The local alliances needed, and the attributes of primary care-oriented academic health centres are useful and practical. The evidence for health benefits of primary care has been clearly summarised. This is a pivotal point in the argument for largescale redirection of resources to primary care. This excellent work done by many and 14
integrated by Starfield changed our argument from the position of ideology and ideas to that of evidence. And evidence requires change in practice (as it is the case in clinical care). The position proposed by The Network: TUFH is unequivocally to share with communities, decision makers and colleagues the information that “primary care produces better outcomes”, and to advocate shifting resources to primary care. The power and practice of the corporate health industry - with the large profit margins in technology, hospital care, drugs and health management - needs to be acknowledged and analysed in the section “Why do so few AHC’s embrace primary care?” This issue would change the goal from ”encourage equitable distribution of primary care resources” to “equitable distribution of healthcare resources”. Primary care is at the divide between corporate profit interest and social responsiveness. Primary care can be the way to change. In a world that increasingly tolerates expanding inequities, a more activist stance is required. From this activist stance, the following areas need attention: equity in healthcare; postgraduate education; the standard of primary care in AHC’s; the role of primary care specialists in planning and integration of the whole health system; the district health system in resourcing poor countries; and the integration of vertical programmes at the level of the individual and the family. This Position Paper is a solid foundation for serious building work. Jannie Hugo | Associate Professor, Department of Family Medicine, University of Pretoria, Republic of South Africa Email: jh38@mweb.co.za
Dr. Jannie Hugo
POSITION PAPER NEWS • Greek translation of Position Paper on Problem-Based Learning available (translated by Evangelos Drosos and Ioannis Dimoliatis): www.the-networktufh.org/publications_ resources/positionpapers.asp • Position Paper on The Need for Research in Primary Care to Solve Global Health Problems now available: www.the-networktufh.org/publications_ resources/positionpapers.asp We would very much appreciate to receive your comments on this Position Paper. Your reaction can be sent to secretariat@network.unimaas.nl
BOOK REVIEW
Challenging But Not Comfortable Reading Book Review of: Interprofessional Collaboration: From Policy to Practice in Health and Social Care Editor: Audrey Leathard ISBN: 1-58391-176-6 New York: Brunner-Routledge
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This review has been published before in Education for Health, Volume 17, no. 3, 2004.
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Part II contains a set of case studies in the UK covering different professions, sectors such as mental health, child abuse, family support services, the elderly, et cetera, and agencies including hospitals, service umbrella organisations and voluntary groups of users and carers. Each chapter places its topic in the historical policy context mandating collaboration and is much easier to
Interesting overviews of interprofessional policy issues are explored in Chapter 5 on ethics, Chapter 17 on users and carers and Chapter 18 on master and servant. These explicitly challenge the ongoing policy rhetoric and centrifugal pull of the National Health Service. Chapter 4 reports on the Australian experience with collaboration under policies of economic rationalism and organisational restructuring. In Australia the professions reasserted their distinctive natures as separate professions as the basis for collaboration.
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This volume raises more questions than it answers. Just focusing on education and training issues: Should interprofessional training take place at the undergraduate or graduate school level or should it occur at the workplace? Should it involve all professionals, professionals who will have reasonable contacts and interactions with each other or just those who will interact with the key worker or gatekeeper? Should health and social service agency managers and administrators be included? Should such training be
follow than the extensive policy history and discussion presented in the introduction and Chapter 2 Policy Overview. Chapters 9, 12, 15 and 16 specifically mention training and development efforts. The few evaluations suggest that attitudes may be slowly changed over time but many expected obstacles remain. Full collaboration occurs in only a small number of instances and the impact on seamless service delivery and quality of care is negligible.
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The policies, however, present a golden opportunity for health educators to have a role in training and facilitating interprofessional collaboration at the individual, professional and organisational levels based on theories of collaborative advantage and the learning organisation (see Chapter 9).
Of most interest to health educators would be Part III: Learning Together, which covers the role of university-based training for collaboration. Chapter 19 presents seven expectations of education that would ultimately support integrated health care: modifying attitudes, establishing common values, knowledge and skills, building teams, solving problems, responding to community needs, changing practice, and changing the professions. Each expectation features a brief programmatic example from the UK followed by both positive and negative commentary. Chapter 21 covers a variety of training models in Norway. One study concluded that students valued shared working over shared learning while in another study students became more sceptical in their attitudes towards group work, interprofessional cooperation and the benefits of knowledge about other professions. Chapters 20 from Canada and 22 from Hong Kong report on the creation of educational programmes along with curriculum and course descriptions. Both chapters conclude that evidence for interprofessional learning is lacking. The Canadians call for better theory while Hong Kong continues support for the policy agenda calling for educational innovations and exploring alternatives by challenging the individual and professional norms along with institutional values.
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Most would agree that professionals should collaborate to provide care that meets the needs of users. To this end, the UK has promulgated policies that attempt to change and re-engineer how professionals work. The 24 chapters in this volume explore the transition from policy to practice, but unfortunately the case for mandated collaboration is ambiguous at best. The authors then rationalise the difference between their findings and experiences on the one hand and their policy agendas and human values on the other. Some claim that a concerted and continuous effort will eventually result in the merger or amalgamation of organisations and professions, thereby eliminating differences and unifying the delivery of care (see Chapter 7). This makes for challenging but not comfortable reading.
ongoing, and if so, how often and in what forms: conferences, workshops, group exercises or on-line?
Harry Perlstadt | Associate Professor, Sociology Department, Michigan State University, United States of America Email: perlstad@msu.edu
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THE NETWORK: TUFH IN ACTION EDUCATION FOR HEALTH Three times a year The Network: TUFH publishes its peer-reviewed, MEDLINE-indexed journal Education for Health: Change in Learning & Practice (EfH). For contributions, please contact efh@network.unimaas.nl
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Transition
among the ways in which a diagnosis is made are ever more sophisticated types of imaging. One thing that is often forgotten, however, is that many of these approaches require electricity and potable water, items that are just assumed. In many places around this world, however, we cannot assume that these are available. Also, what is a good healthcare provider in one place is only a good healthcare provider in thĂĄt place. Place matters and The Network: TUFH calls attention to that fact. May it do so forever! Even if it is not popular, it is very important.
Fortunately for the journal - and thus The Network: TUFH - I will be succeeded by two extraordinary people: Margaret Gadon and Michael Glasser (read about Margaret and Michael further down in this section). One person resigns and is replaced by two! That bodes well for the future of the journal, not only because it combines the perspectives of a physician/teacher with that of a sociologist/teacher, but both bring the support of their home institutions to this task as well.
I will miss the journal: reading the many submitted manuscripts, writing an editorial now and then, and putting together each issue. None of this could have been done, however, without the commitment and dedication of the managing editor, the journal’s secretary, and the insights of the associate editors, as well as the important work of our many reviewers and editorial board. My thanks to all of them. I know that the journal is in good hands. Good luck and all the best for the future!
The Network: TUFH is a small voice in the wilderness. It cries out for relevance to the needs of societies everywhere. This is a time in which high technology is a priority, and 16
EDUC ATION FOR HEALTH ONLINE Since 2000 Education for Health can also be read online. We are glad to hear that this is of good use to our members:
As of the first issue of 2006 I will step down from the editorship of Education for Health: Change in Learning & Practice, a journal that is now Medline listed. It was a very difficult decision to make and one that took me a very long time. My experiences with the journal and The Network: TUFH have been extraordinary. Because of my editorship I have been an ex-officio member of the Executive Committee and before that I was an elected member. I was also privileged to have been one of the founding members and as such attended the very first Network meeting in Kingston, Jamaica. From the very beginning, The Network has placed values before techniques (educational or otherwise). In fact, I have found throughout my career it to be one of the few organisations that does. The journal serves many purposes. It serves as a communications tool for readers to learn about innovations world-wide, and it also helps those for whom English is not their first language to present their ideas and evidence on paper.
Dr. Ron Richards
Ron Richards | Editor EfH Email: limaron@aol.com
Dear Editorial Board, Thank you very much for the possibility to have online access to Education for Health. It was a lot of help last year, and I have no doubt that it will be very helpful again this year. Sincerely yours, Ricardo Angeles | School of Medicine, Ateneo de Zamboanga University, Philippines For the Table of Contents of Education for Health - Vol. 18, No. 1 please visit angelina.ingentaselect.com/vl=6453712/ c l = 12 5 / n w = 1 / r p s v / c w / w w w / tandf/13576283/v15n2/contp1-1.htm
New Editors Education for Health First, we would like to thank The Network: TUFH for giving us this opportunity, and express appreciation to Ron Richards for all his hard work with the journal in the past few years to produce the quality publication it is today. In the future, we would like to broaden the journal to reflect the mission of The Network: TUFH as “an organisation devoted to both the education of health professionals, and to the improvement and sustainment of health in the communities they serve”.
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After studying Sociology at Colorado State University, Dr. Glasser got his Ph.D. in Medical Sociology in 1983 at the University of Illinois. The University of Illinois is also were he started and continued his career: from research assistant to his present functions. In addition to this, he was also Visiting Assistant Professor of Medical Sociology at Rockford College and Northern Illinois University.
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Michael Glasser is Assistant Dean for Rural Health Professions/Research Associate Professor of Medical Sociology, Department of Family and Community Medicine / Director Centre for Rural Health Professions at the University of Illinois College of Medicine at Rockford, USA.
projects (e.g. Export Centre for Excellence in Rural Health, Faculty Development for Family Physicians) and his membership of the Organising Committee of WHO’s First Global Conference on Medical Education and Medical Practice, and of the Research Committee of the Illinois Rural Health Association. Dr. Glasser also received an Award of Merit for Outstanding Community Service from the Illinois Rural Health Association.
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Dr. Gadon received her medical degree from Albert Einstein College of Medicine
and her public health degree from Johns Hopkins.
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In addition to issues of health equity, she is interested in the integration of medicine and public health at the level of training, interdisciplinary medical education and international community health. In addition to her health policy work, she is currently teaching in the Patient, Physician and Society course at Northwestern University School of Medicine.
Dr. Margaret Gadon
Margaret Gadon and Michael Glasser | Co-editors EfH (starting Vol. 19, No. 1) Email: margaret_gadon@ama-assn.org; michaelg@uic.edu
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Margaret Gadon is currently directing the initiative on Health Disparities at the American Medical Association, where she has worked since October 2004. Prior to that she worked as a community health physician and directed the Community Medicine programme for medicine-pediatric residents at Baystate Medical Center in Springfield, USA, served as a medical director of a migrant health worker programme, and worked as a public health physician for the New York State Department of Health.
Finally, we would like to provide researchers and programme developers the opportunity to share their work in progress, through educational and research updates. J U N E
Consistent with the Network: TUFH’s framework, we will be targeting multiple stakeholders: policy-makers, health managers, the health professions, academic institutions
Dr. Michael Glasser
and communities. Specifically, we plan to increase the scope of the journal to include health services research, health policy issues, international health, and community health studies. We plan to build some short-term partnerships with other journals to continue the tradition of occasional special theme issues.
Dr. Glasser’s special interests are family and community medicine, and rural health. This is mirrored by his (research) 17
IMPROVING HEALTH HEALTH SERVICES
Tsunami The Killing Wave December 26, 2004 will be forever imprinted in Thai minds. In the late morning, two giant waves of 10 to 12 meters high swept across six provinces on the West coast of Thailand along the Andaman sea.
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Never before had we had such an experience. More than 12 hours later, the whole country got shaken and shocked when we saw how much destruction the wave had caused in our country and in 11 others. Great Rush of Initial Aid Before the Government took the supreme command, the public and private health sector responded to the situation and cry for help from the six provinces’ health services and health professionals. Regional and university hospitals nearby immediately sent medical and surgical teams with equipment, supplies and vehicles to the provincial and district hospitals. They performed life-saving procedures and operations, gave first aid and transferred necessary cases to the nearest, safest and best suitable hospitals. They stayed overnight and took turns with local staff until official aid came. From the start the Medical Director of the Forensic Science Institute - Ministry of Justice - foresaw the importance of body identification, so he started that process about 20 hours after the report of the incident. The gathering, which was approximately 100 bodies at the time, became thousands in a day. Seven teams of forensic doctors from five university hospitals, the police and the Ministry of Justice teams cooperated in the process. They recruited volunteers, set up a filing system, and applied modern available technologies including microchips, dental records, and DNA sampling. The most important thing was to deliver the body’s home to their families. In conclusion, aid started immediately for the injured and deceased. Although it 18
seemed unorganised at the beginning, the Government eventually took control by setting up a collaboration centre for information on the third day. Several measures were implemented, especially regarding safety, hygiene and health control - to prevent an outbreak of epidemics. Havoc after the tsunami The Recovery By February 22, 2005 the death toll in Thailand was 5,395. Still missing were 2,993 people, with more than 8,000 people injured. The damage to properties and businesses was estimated at billions of dollars, especially in the tourism industry (at the beachfronts). Today, April 26, 2005, is the four-month anniversary of the disaster. The days of catastrophe have passed. Thailand is entering the recovery stage, although slow and uncertain. After the tsunami, more than 10,000 mental therapy and counselling sessions were carried out. Today 400 affected people still need medication, 800 remain hospitalised, and around 400 orphaned children are still receiving counselling. There are around 50 psychologists from 17 mental health centres nationwide assigned to spend a week in the affected area. Early in April, all amputees were given legs, arms or hands prostheses by the Sirindhorn National Rehabilitation Centre, with technical aid and supplies from a German company. Some fishing boats were repaired, and new ones were being built with the financial and technical aid from the Royal Thai Government, foreign groups and organisations. Temporary tents and shelters were replaced by housing, built by workforces from the military sectors.
During this summer vacation, a short-term community services project will be supported by the National Health Security Office, involving 4,000 (volunteer) university students. These students will provide various relief work for villagers, take care of children by organising extra-curricular activities, encourage older citizens, provide information on their healthcare needs and health problems including issues as sanitation and nutrition, and offer more rehabilitative projects. All of these efforts will bring the fishermen back to the sea and the villagers back to their life. Meanwhile, they live on cash and supplies donated by the Government and private organisations or foundations. The long-term plan is still unclear. What is clear though, is that there must come a tsunami warning system to cover all uncovered regions. Global communities are observing the utilisation of their donations to Thailand and other affected countries. Thai Government will need to have satisfactory answers to all their questions, especially regarding the plans for a warning system and future protection against natural disasters. Nitaya Wongsangiem | Assistant Professor, Faculty of Medicine, Thammasat University, Thailand Email: nitaya@alpha.tu.ac.th
RURAL HEALTH
An Action Plan for Rural Health The Wonca (World Organisation of Family Doctors) Working Party on Rural Practice (Roger Strasser, Bruce Chater, Australia; James Rourke, Canada) was started in 1992. In 2003 the issue of developing a Global Action Plan on Rural Health was put into practice.
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The components of this local action progress include the following mechanisms: • Establishing community empowerment including community development, community participation and local capacity building. • Building unity of partners between patient care and public health through primary healthcare.
Ilse Hellemann | Wonca; WHO Liaison Person Email: ilse.hellemann@hosan.at
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Intentions and Contents The progress begins with local thought and planning and then proceeds to rural action (‘bottom-up’). Then, it anticipates transferring local successes to a global level - and through this transition back to other rural sites.
Draft Resolution for the WHA Recognising that e.g.: • Many developing nations cannot afford a full complement of well-trained medical specialists. However, all nations can afford to adopt the concept of family and community medicine for its primary healthcare workers, which will improve the quality of healthcare substantially. • With the concentration of poverty, low health status and high burden of disease in rural areas, there is a need to focus specifically on improving the health of people in rural and remote areas. • There is a particular need to focus on the health and well-being in rural and remote areas so as to break out of the poverty-ill health-low productivity downward spiral.
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The active Director-General of WHO, Dr. Jong Wok Lee, has renewed the emphasis on primary healthcare and healthcare services for vulnerable populations.
Recommends that the Director General e.g.: • Supports endeavours of Member States to reorient their policies to improve the health of people living in rural and remote areas. • Reports every five years to the WHA on progress made by Member States in improving the health of their rural populations. • Collaborates with international agencies such as Wonca and other NGOs in official relations with WHO in developing an action plan to improve the health of people living in rural and remote parts of the world.
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Wonca has formally expressed its commitment to Develop Family Practice and training in the areas of greatest needs, in the spirit of equity, when defining its priority goals in 1998.
To achieve these goals, the Action Plan needs broad support by people and populations, professional groups, NGOs and media (the ‘public’, the ‘social society’), but also by Governments and Departments of Health. Therefore, the Wonca Working Group on Rural Practice has drafted a paper and distributed it to the Government representatives on occasion of the World Health Assembly (WHA) in May 2004. There is hope that this working paper will serve as a draft resolution to be submitted to a future global forum, who then may endorse and adopt this as their global strategy.
Urges Member States e.g.: • To reaffirm their commitment to primary healthcare oriented systems and better political distribution and use of health resources for people in greatest need. • To encourage better coordination and integration of individual and public health interventions targeting a given population. • To mobilise principal stakeholders in health, normally policy makers, health managers, health professionals, academic institutions and communities, to become more socially responsive and accountable. • To identify strategic options at the local level to cope with constraints and opportunities in building coherent and efficient interventions in favour of people living in rural and remote areas.
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Rural populations, especially in developing countries and regions in transition, but also in remote areas of developed countries, are often disadvantaged regarding resources. Rural areas are hit worse by poverty and migration, both of inhabitants and of qualified health professionals, and their deprived and vulnerable populations certainly need special attention and development plans.
• Providing rural health services, and improving quality and access to health services, for people living in rural and remote areas of the world. • Developing action-oriented research to develop new knowledge to support our efforts. • Changing education and performance of health professionals to improve education and training for rural health practice.
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IMPROVING HEALTH HEALTH RESEARCH
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In order to develop a country’s research capacity effectively, we need to prioritise how and who will benefit from the research products. Without focussing on the priority problems in health research capacity, people will be trained, organisations built and institutions strengthened with no clear end goal. Countries should look at where capacity is most required and enrich these areas first (COHRED, 2000) (Boelen, 2001). In the past, health research in Iran has been characterised by low adherence to priority research, and removal from the communities’ real health needs. The situation could cause a wider gap between the universities and the people’s needs. The Necessity for Empowerment During the past three years the Universities of Medical Sciences in Iran attempted to develop equity in health. Their modern approach of participatory health research priority setting (they are responsible both for medical education, research and delivering healthcare to defined the population) pushed them to revise their policies towards shortening the 10/90 gap by building partnerships in health research activities (Asefzadeh, 2003). Qazvin University of Medical Sciences (covering a population of about 1100,000) also revised and developed its health research policies towards socially accountable goals. They were successful by involving a broad range of the main stakeholders, determining the health problems of the people, and formulating those health problems into more than 200 research topics. According to these topics, the versatile health teams led by the academicians are to launch community-based research projects. Now, lay persons included in the research team do not have the same knowledge as the experts and this condition leads to misunderstandings. We need to build the capacity to mobilise the resources through continuation of the coalition.
Housewives and female community health volunteers participated in the workshops to be empowered in critical thinking as well as in participating in the community-based research projects
Bridging Gaps To bridge the cultural gap between the community and the academicians (Richards, 1996), we organised some meetings and assessed the learning needs of the community volunteers for action research. Setting the learning objectives, we prepared a specially designed practical guidebook for their training and organised several workshops. More them 110 people, under whom NGO members, housewives and female community health volunteers, participated in the workshops to be empowered in critical thinking as well as in participating in the community-based research projects. Now they are capable of problem defining and analysing, data collecting and processing, and examining the interventions independently. They collaborate with researchers in nine participation health research projects. Some of them also motivate and train the other volunteers in action research. Our experience is to be generalised to other universities. Conclusion The critical first stage in any participatory process is to lay the basis for the relationship between the project workers and the community. The key issue is the fact that community participation is the key to the project, not merely an input to the outcome. Our experience indicates that the
community volunteers within the research team can facilitate: • getting entrance to the selected community, • getting to know the community and creating awareness of the project, • gaining the trust of the community, • managing operations of the project, • establishing the basis of community participation to develop the project, and • mobilising and pooling the resources. Our experience in Iran reveals that empowerment of the community in action research can develop skills and abilities, to enable people to better facilitate and manage the process of participatory research. People can become the real owners of the research results, and they can stride towards equity in health. On the other hand, by bridging cultural gaps, the researchers’ and academicians’ attitudes towards responding to the real health needs of their communities are reoriented. It is a give-and- take process. References ASEFZADEH, S. (2003). Building up partnership: Setting health research priorities. Network: TUFH Newsletter. The Network: TUFH, December 2003: 7. BOELEN, C. (2001). Towards Unity For Health. Case studies. Geneva: World Health Organization. COHRED (2000). The ENHR handbook. Document 2000.4. RICHARDS, R.W. (1996). Building partnership, educating health professionals for the communities they serve. Jossey-Bass Publications. Saeed Asefzadeh | Associate Professor, Director of Research, Qazvin University of Medical Sciences, Iran Email: sasefzadeh@qums.ac.ir
HEALTH AUTHORITIES
“Normality is Still a Long Way To Go”
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THE PROBLEM OF HEAT AND SANITATION IN THE RELIEF CAMPS IS DISTRESSING. THE SHELTERS HAVE TIN ROOFS AND THE EARLY SUMMER TEMPERATURE HAS ALREADY REACHED 40 DEGREES CELSIUS.
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Christian Medical College & Hospital, Vellore, responded to the emergency at once. Several teams of doctors (from different specialties) and social workers were sent to the Nagapattanam district (one of the worst affected districts). Money, clothes, blankets et cetera were distributed immediately and primary health problems were attended to. Under supervision, a team of counsellors evaluated the psychological morbidity, and trained the public health workers to identify vulnerable people. Community health nurses and general nurses have been carrying out preventative health education on communicable diseases. An action plan has been worked out concerning the need for sanitation, community reorganisation, and
Shubanker Mitra | South East Asia SNO Representative, India Email: smitracmc@rediffmail.com
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Others Helping In spite of the Government’s best efforts, there is a shortage of supplies. Numerous NGOs are stepping in to fill the lacunae.
Today, five months after the tsunami, the problem of heat and sanitation in the relief camps is distressing. The shelters have tin roofs and the early summer temperature has already reached 40 degrees Celsius. In spite of all the efforts, normality is still a long way to go.
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Government Action The State Government reacted swiftly and efficiently to this national disaster. In the 12 districts, 325 relief camps were established in schools, colleges, community centres, and marriage halls to provide temporary shelter. Lakhs of food packages were distributed (1 lakh is 100,000 rupee). Over 350 teams of doctors and health professionals were sent into the affected areas to stall the outbreak of epidemics and undertake primary
The second major challenge for the Government is the restoration of the means of livelihood. The Government offered to subsidise new boats and nets (or the repair of old boats) for the affected fishermen, but the fishermen’s association did not accept these terms and decided not to resume fishing until subsidy is raised to 50% and provided to all. At present the Government is providing Rs 1,000 and dry rations to the affected families. The Government also proposed to build new houses beyond a safe 500 meters from the coast to reduce damage in the event of similar natural disasters in future.
psychological rehabilitation. Sources within India and abroad were encouraged to help in cash and kind.
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Psychological Distress In the immediate aftermath there was a widespread distress and acute stress among the survivors. Many were unable to sleep at night, while others had nightmares on the tsunami wake them up. The memory of the giant roaring tsunami waves, together with the cries of the helpless children, filled them with dread. Continued apprehension of a second tsunami - fuelled by the local media sensationalism - added to their psychological instability. Over the weeks the psychological distress settled down, and now there is time to grieve for the losses (of family members, or lives possessions). Follow up reports show that Post-Traumatic Stress Disorder does not appear to be a widespread problem.
healthcare work. Fearing wound infection as a major problem, mass immunisation programmes against tetanus were carried out immediately. No reports of any epidemic have been received so far. Also entire disaster-hit villages were fumigated, and all the water sources and dark slush were chlorinated.
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On Sunday, 26th of December, 2004, the tsunami waves struck the coastal regions of South India, catching people totally by surprise: fishermen in the sea, their families in thatched houses on the coast, and children playing on the beach. Over 12,000 people were washed away without warning. Hundreds of families were separated, and most of them lost one or more family members. The fishing community has lost their means of livelihood, as most of their boats and nets now lay damaged beyond repair. There is a bizarre contrast between the normal lives of the costal towns lying two kilometres from the coastline and the ruined hamlets that dot the entire coastline.
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Jogjakarta Medical Rescue for Aceh
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The beautiful and historic Indonesian province Nangroe Aceh Darussalam (NAD) became a province of corpses in the wake of a monstrous tsunami that swept across it on December 26, 2004. Immediately after the tragedy, Sardjito Hospital Jogjakarta in collaboration with Faculty of Medicine, Gadjah Mada University, decided to provide emergency assistance by sending three medical teams to the affected areas: Jogjakarta Medical Rescue for Aceh. They all went to Meulaboh, one of the most severely devastated areas.
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Team 1 The first medical team went to NAD on December 30, 2004, offering medical emergency help and performing rapid assessment of victims’ basic needs after the disaster. This team consisted of doctors, nurses, technicians, nutritionists, and sanitarians. The team was divided into two sub-groups: the first group focused on revitalising the local hospital, the second group formed a mobile team that provided medical services in refugee camps. The local hospital building was badly damaged. All of the equipment was destroyed, sunk in thick mud and salt water. The hospital had lost many of its patients and more than half of its staff. The Jogjakarta team, together with volunteers from local and international institutions, worked side by side to clean up the hospital. They focused on reactivating the emergency unit, wards and surgery rooms, and providing medicine. Since it reopened, the hospital has been receiving 500-700 outpatients every day. The most common diseases suffered by disaster victims were bad wounds, pneumonia, upper respiratory tract infections, diarrhoea, and tetanus. The mobile team went to 29 refugee camps, provided medical services to difficult-to-reach areas, and performed evacuation of severe patients.
A mobile team provides medical services at a refugee camp in Samatiga Meulaboh The first team faced many obstacles: difficulties in obtaining clean water and hygienically prepared food; a complete electricity and communication blackout; lack of medical personnel, facilities and drug stock; minimal transportation facilities; and minimal coordination because of the permanent flow of many volunteers from many institutions in a short time. Team 2 and 3 The second team went to Meulaboh on January 4, 2005. Their mission was to continue the programme of the first team. They coordinated a triage team, pioneered work in the psychiatry clinic, organised a drug service, performed daily records of the patients, gave tetanus vaccinations, completed facilities for the ward/surgery room/nutrition installation, provided better nutrition for patients, and conducted blood transfusions. The team worked jointly with other institutions. The Indian Navy, for instance, provided a hospital ship that ran 24 hours a day, accepting referral cases from the local hospital. Together they performed approximately 10 surgeries per day, and helped 70 patients per day in the policlinic and 450 patients per day in the emergency room. The third team departed for NAD on January 13, 2005. Besides providing medical help, they also worked as liaison officers, coordinating work at the local
hospital, and co-operating/networking with teams from other countries. Humanitarian Aid Also in Jogjakarta itself, many activities were organised to support and help NAD. The Jogjakarta rescue team was funded by money collected by Sardjito Hospital and the Faculties of Medicine and Psychology of Gadjah Mada University. The Jogjakarta committee provided the latest information from Banda Aceh and Meulaboh through satellite and cellular telephone. Sardjito Hospital also provided a psychosocial clinic for Acehnesse who live in Jogjakarta. Together with World Vision, Harvard University, Melbourne University, and Kobe University, Sardjito Hospital and Gadjah Mada University are making medium and long-term plans for Acehnesse’ health rehabilitation. Although the Government has declared that the emergency in NAD is nearly over, the rescue teams will continue to go to tsunami-devastated areas to build a better health and medical system. Humanitarian aid is not only important during the emergency but also during rehabilitation, reconstruction, and recovery. Dr. Soetaryo | Commander in field Jogjakarta Medical Rescue for Aceh; Sardjito Hospital; Faculty of Medicine, Gadjah Mada University, Indonesia Email: harsono_2000@yahoo.com
INTERNATIONAL HEALTH PROFESSIONS EDUCATION MULTIPROFESSIONAL EDUCATION In this recurring column topics are discussed regarding multiprofessional education (MPE). The Network: TUFH has decided to adopt the terminology ‘multiprofessional’. Readers are invited to share their views and/or experiences on/with MPE, or react to articles in this column.
Interprofessional Education Moves Forward in Canada ting out a programme for curriculum change, evaluation, knowledge dissemination and community interactions.
“Health care delivery models of the future clearly envision teams of health care providers working together to meet patient needs. Therefore, there is interest in looking at collective education and training opportunities.” (Health Council of Canada, January 2005)
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The College of Health Disciplines at UBC and its partners are focusing on capacity building and fostering system change. This partnership has already established the foundations for a provincial network; developed an online orientation to IECPCP; established a plan for scholarships and provincial workshops; and coordinated with the provinces of Manitoba and Saskatewan in set-
When Health Canada announces funding for IECPCP projects in late April, work will begin on building a Pan-Canadian network of all the projects. The network of participating sites already established in British Columbia has held six meetings of its Steering Committee to ensure that when funding is released, British Columbia will be ready for the challenge.
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Provincial Response The College of Health Disciplines at the University of British Columbia (UBC) has coordinated a provincial response in collaboration with health authorities and other universities and colleges. It established a provincial steering committee in July 2004, which includes universities, colleges and health authorities as part of a planning process.
New IPCPCP initiatives being planned include: developing a provincial forum on issues in rural maternity care; building best IPE practices in Aboriginal communities; applying the primary healthcare logic model to IPE; developing IPE in community health centres and in residential care facilities.
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The kinds of projects that will be funded by the IECPCP initiative include: a focus on education and training, linked to practice;
IPE activities, pre- and post-licensure; creation of a clinical learning environment which models competencies; curriculum development and evaluation; and networking and knowledge translation. Projects will only be funded that demonstrate their sustainability past the period of federal funding and that can show that they have been clearly evaluated.
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Goals The goals of the funding programme for IECPCP are: promote and demonstrate benefits of IPE; stimulate networking and best approaches; increase the number of health professionals trained in IPE; increase the number of educators to teach IPE and to facilitate interprofessional collaborative care in education and practice settings.
Dr. John Gilbert
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Canada is taking a leading role in developing interprofessional education (IPE) for collaborative patient-centred practice (IECPCP). A Royal Commission, chaired by the Right Honourable Roy Romanow, researched healthcare in Canada, and reported their findings in November 2002. The provinces and territories of Canada signed a First Minister’s Accord in January 2003. That Accord addressed issues in health human resource planning, problems of recruitment and retention of health and human service workers, and IPE. Health Canada established a National Expert Committee in July 2003 to address the issues associated to IPE – the author is a member of that committee. Health Canada issued a request for proposals in the fall of 2004, with funding for two years of about Cdn$14 million for projects in IECPCP.
Projects Many of the IECPCP programmes being proposed include rural sites, and all have at least six health professions associated with them. The Interprofessional Rural Placement Programme developed in British Columbia over the past three years will play a key role in this approach. During the first two years of the IECPCP initiative, there will be central coordination, which will then devolve to health authorities. There is already a gradual move to developing an online curriculum, which will allow learning to be streamlined.
John Gilbert | Principal, College of Health Disciplines at the University of British Columbia, Canada Email: john.gilbert@ubc.ca
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INTERNATIONAL HEALTH PROFESSIONS EDUCATION PROBLEM-BASED LEARNING AND COMMUNITY-BASED EDUCATION
Community-Based Education in Brazil
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In 1996 a process of change started among Brazilian medical schools, resulting in implementation of new curricula. The challenge was to innovate the teaching method and to produce graduates who could cater for community health needs (Iwama de Mattos et al., 1998). It is remarkable that it is only now that we in Brazil are introducing what the Canadians and Dutch did more than 30 years ago. New Courses The State of Mato Grosso do Sul is located in the West of Brazil. Within the State lies the region of Pantanal: the biggest area of wetlands in the world, in size comparable to Portugal, Switzerland, Belgium and the Netherlands combined. The population of 2,078 includes a large number of native Indians and ‘people without land’ who have migrated from other States, in the hope of finding a piece of land to cultivate. Many of these people lack the provision of adequate healthcare. For 45 years there has been only one public medical school in the State of Mato Grosso do Sul. This institution served the entire State and attempted to produce graduates who could provide healthcare throughout this large region. In 2000 a new medical course was implemented at the private Brazilian University for the Development of the State and the Region of Pantanal (UNIDERP). UNIDERP’s mission statement is based on the commitment to support the development of the State of Mato Grosso do Sul - in particular the region of Pantanal with an innovative PBL curriculum that is capable of responding to current demands. At the same time that the medicine course was implemented, a course in psychology was also created. Community Programme Both courses are based on community-oriented education. That topic offered the opportunity for a transversal module: the Inter24
institutional Programme for Teaching, Service and Community Interaction (PINESC). This is a community-based educational programme established by UNIDERP, together with the preceptors and health professionals of the Family Health Team of the Family Health Programme. It guarantees the desired interaction between teaching, service and community. From the first year, students of both courses attend once a week a Basic Health Unit (the working rationale of the Brazilian Health System, Health Promotion and Primary Care) in the community. In the third semester families are assigned to students. Students undertake supervised home care and carry out surveys to establish the epidemiological profile of the micro-area (in order to identify the main local health problems). These activities are frequently used as themes for research projects, which can help students to identify suitable solutions for the health problems of the community (Cabral et al., to be published). PINESC has been developed in parallel with the thematic blocks of the medical and psychology curriculum, which combine to form the annual course content. Tutorials are followed by laboratory activities in the Skills lab and the Communication and Integrated Practice lab. The student can perform or observe some fundamental laboratory practices, complementing the theory and their observations in the community. Since its creation, PINESC has been modified and adapted to meet the needs of the teaching services and the community. Paving the Way PINESC gives students the opportunity to experience the reality of public health and community. The experience gained will undoubtedly provide a valuable addition to a broad education, which bodes well for their future professional lives, as well as assisting in the acquisition of professional competence. PINESC also paves the way for student’s Primary Care internship. As internists,
Centro de Especialidades Médicas - UNIDERP outpatient clinic and the UNIDERP campus the students are able to demonstrate their professional skills with confidence due to thorough preparation during the previous four years at PINESC. By the end of 2004, when the first year of internship ended, the results were evident and satisfactory. Besides receiving a professional training, students were prepared for citizenship, and to acknowledge the rights of the individual, as paradigms of the transforming praxis towards a fair, fraternal, and solidarity-based society. References CABRAL, P.E., IWAMA DE MATTOS, M.C.F., MACHADO, J.L.M., MACHADO, V.P., POMPILIO, M.A., VINHA, J.M. & KODJOAGLANIAN, V.L. (to be published in 2005). Community based and oriented education integrated to the curriculum preparing physicians and psychologists: the case of PINESC. An example of institutionalization of extension activities at UNIDERP. IWAMA DE MATTOS, M.C.F., MACHADO, J.L.M. & CHAVES DOS SANTOS, P. (to be published in 2005). Leadership and governance in the new curriculum of a new school and in curriculum reform. IWAMA DE MATTOS, M.C.F., MACHADO, J.L.M. & RUIZ, T. (1998). Teaching in the community. Changing and implementing a new curriculum. Education for Health, 11/3: 319-325. Paulo Eduardo Cabral and Maria Cristina Iwama de Mattos | Coordinator PINESC, Medical Course UNIDERP, Mato Grosso do Sul, Brazil; Consultant in Medical Education to UNIDERP Email: mcfimattos@laser.com.br
RURAL HEALTH PROFESSIONS EDUCATION
Women’s Arms and Skills for a United Community
Collecting the garbage with borrowed vehicles
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People from all over the country now visit Sta. Cruz and learn from the women’s experiences. It has served as a guide and inspiration for the students and faculty of Community Medicine of the UP College of Medicine.
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At present, while continuing to manage their solid waste programme, the women of Sta. Cruz have extended their efforts in other income generating activities for the members of BIGKIS.
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BIGKIS As a result of the efforts of the UPCM faculty and interns, the women of Sta. Cruz revived an inactive organisation which they called BIGKIS, an acronym for Bisig at Galing ng Kababaihan para sa Iisang Sambayanan (roughly translated “arms and skills of women for a united community”). Through this organisation and with very minimal start-up funds, the women organised educational trips for themselves to nearby provinces with successful waste management programmes. Armed with the concrete experiences of other communities, the women launched an intensive information campaign in their barangay regarding waste segregation, recycling of non-biodegradable waste, and composting.
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Materials recovery facility
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With a little help from the men in the community, the women succeeded in converting an old unused chapel into a Materials Recovery Facility, which they formally inaugurated in December of 2002. Here, they gathered - and later sold - recyclable wastes that they collected from the community, earning modest funds for BIGKIS. These funds were later augmented with monetary awards initially from the Mayor and later from the National Government, which the community received for their organised efforts in visibly reducing the garbage in the community. In July 2004, Barangay Sta. Cruz won 5th place in the national search for the model barangay.
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Priority Health Problem In September 2001, a team of interns and their faculty preceptor conducted a workshop with barangay (village) health workers - or BHWs - in the programme area to determine what the BHWs perceived to be their priority health problem. In this workshop, the BHWs were asked to visualise a picture of a healthy community. The BHWs were then asked what their barangays would need in order to achieve such a picture. For the BHWs of Barangay Sta. Cruz, garbage was the priority problem. The next group of interns, together with the BHWs of Sta. Cruz, then conducted a survey to see how other members of the community perceived the problem. Though the survey showed that less than 50% of the surveyed population perceived garbage to be a major problem in the community, 80% of the respondents were willing to participate in a waste management programme. As a result, the next batch of
interns studied the Philippine Solid Waste Management Act and other related documents, simplified and translated these documents, and conducted study sessions on the subject with the BHWs and the Village Council. Later, interns facilitated the attendance of the BHWs and the Village Council in a national forum on Zero Waste Management. After all these activities, the UPCM team was asked by the Village Council to invite an expert on garbage management to talk to the community. After a well-attended seminar in the barangay conducted by the invited speaker, the women of the community decided to carry on the waste management programme.
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Medical students in the Philippines are required to rotate in Community Medicine in their internship year. At the UP College of Medicine (UPCM), interns immerse for six weeks in a rural Community-Based Health Programme maintained by the Community Medicine Faculty of the Department of Family and Community Medicine, in partnership with the Local Government Unit and the people of the communities. At present, the programme area is located around 60 kilometres South of Metro Manila in the municipality of Sto. Tomas in the province of Batangas. The programme provides learning opportunities for both faculty and medical students in the principles and practice of community medicine through activities that directly address expressed community needs, and assist these communities to increase capacities in their own healthcare and development.
Elizabeth Paterno | Associate Professor, College of Medicine, University of the Philippines, Philippines Email: bpaterno@info.com.ph
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INTERNATIONAL HEALTH PROFESSIONS EDUCATION DISTANCE LEARNING
The Culture of Distance Learning... It’s Not About Technology!
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Here we are, five years into the 21st Century, reveling in a technology- driven global information community. The age of ‘just in time’, where faxes, cell phones, tablet computers, audio/video connectivity, and satellite suspend the boundaries of space and time. Information is just a finger tap or voice command away. How then, do we insure the quality of education that is delivered across the world to individuals from various cultures and languages in preparing the healthcare providers of the future?
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Enabler First, it is important to clarify that technology, in any form, is an enabler. It is an instrument which, when properly used, enables that communication can be used for many purposes, including for education. The current generation of students was born into the information age. Technology is an accepted - or should I say expected form of communication, entertainment, and play. Technology has been integrated into education as a modality of knowledge access since their first day of school. During their learning years and/or early years as instructor, faculty did not have access to the diversity of technology. Therein lays the conundrum, a generational divide (Oblinger & Oblinger, 2005) in which expertise with use of technology is on the side of the student and not the faculty. However, learning is NOT about technology. Definition Distance education is defined by the American Association of Colleges of Nursing (AACN) (American Association of Colleges of Nursing, 1999) as “those learning strategies designed to meet the learning needs of students outside of a traditional classroom setting where the instructor and student are separated by time and space”. AACN differentiates between distance education and distance education technologies and
defines the latter as those resources needed to support distance education. Those resources include financial, equipment, software frameworks, and human/institutional systems support. Technology is the enabler, the tool that allows distance education to transpire. A pivotal criterion for distance education is the design of the learning environment, a responsibility of the Faculty. Mrs. Annette Greer Creating Distance Education How do we create a culture of distance education that has rigor, engages the learners, and promotes behaviours for lifelong learning? The on-line environment of learning must be learner-centred. The faculty designer must consider the characteristics of the learners. Are the students typical young adults with limited responsibilities or are they mature adults with external demands on time and resources such as work and family? The design should take into consideration multiple learning styles and be inclusive of on-line strategies that can meet the strengths of those learning styles. If the design is for world-wide delivery, then the cultural differences in meaning attached to language and its use will need to be considered. A variety of media is available to enhance delivery of education, but the primary focus should be on the pedagogy. Interaction between the content, instructor, student, and peer learners is important for learning to be realised (Weimer, 2002). The question for the faculty designer is: ‘How does the interaction support the purposes of learning?’ Faculty can increase intentional learning interaction through collaborative learning strategies with peers. Collaborative learning strategies support social and interpersonal skill development (Huang, 2002).
When collaborative learning strategies are used in social learning environments, with multiple disciplines and with common learning goals, knowledge construction and critical thinking skills are advanced. It is essential that faculty adapt to being a ‘learning facilitator’ in collaborative learning designs rather than just a ‘content lecturer’ (McKeachie, 2002). Such strategies require a transition in control of learning allowing the student to assume greater responsibility and accountability in setting learning goals (Weimer, 2002). In addition, distance education should provide authentic learning. Learning is authentic when it is based on real life experiences and can be achieved by use of inquirybased, case-based, and problem-based learning strategies (Huang, 2002). Authentic learning opportunities serve to motivate students and bridge the gap between academic environment and skills needed to function in the future healthcare environment. The quality of distance education can be measured in the ability of the students to reflect on their own learning. The ability to use high order thinking skills to solve problems in healthcare and to use technology as an enabler for lifelong learning becomes the evidence needed to validate the quality of education acquired.
COMMUNITY ACTION NEW INSTITUTIONS AND PROGRAMMES
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The organisers welcome world-wide applications. For information and application forms, please contact leni.noteborn@ afn.unimaas.nl or visit the website at www.afn.unimaas.nl
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The curriculum of the Faculty of Medicine, Maastricht University, has been translated into Chinese and is available on CD-ROM. In case you are interested, please email to: welcome@oifdg.unimaas.nl
What contribution can the Faculty make to improve community health? In my country, in order to improve community health, the Faculty can design plans and provide the human resources to carry out these plans.
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After the second year, successful candidates are entitled to a Masters Degree in Affective Neuroscience, jointly awarded by the Universities of Maastricht and Florence.
Does the fact that a Faculty is settled in a community with its educational programme have any impact? Does it lead to anything within the community? Yes, it does. In order to accomplish anything within the community, not only a Faculty must be settled in the community, but also the Faculty members must be community members (and in particular community governors, e.g. Government officer or religious dignitary).
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In the second year candidates write and defend a dissertation. They follow a number of e-workshops and attend a one-week series of top seminars. The programme is largely tailored to individual needs by means of a personal portfolio for each candidate, in accordance with the Faculty’s standards.
What is in your opinion the most important factor in the relationship between the Faculty and community? The most important factor is the good that the Faculty can do for that community. This benefit may be simple, such as a lower fee for good quality healthcare.
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The first year comprises two intensive residential conferences and requires the candidate to complete an approved research project under distance mentorship. Successful candidates are awarded the European Certificate in Anxiety and Mood Disorders.
What is your definition of a community? A community is a group of inhabitants that have one or more similar characteristics, such as race, religion, culture, and social rank. The more similar the inhabitants are, the more solidarity there is between them. I belong to a multicomposition community myself: its inhabitants only have one character similar - race.
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Annette Greer | Assistant Director for Recruitment, Office of Interdisciplinary Health Sciences Education, East Carolina University, United States of America Email: greera@mail.ecu.edu
INTERN ATION AL MASTER IN AFFECTIVE NEUROSCIENCE The Maastricht and Florence Universities, the Psychopharmacology Unit of the Bristol University, the Sackler School of Medicine in Tel Aviv, and the Vita-salute University of Milan, organised a joint postgraduate programme towards an International Masters Degree in Affective Neuroscience. This is a two-year, part time curriculum, for holders of a degree in medicine, psychology or related disciplines. The programme is aimed at research-minded clinicians pursuing excellence in the field of affective pathology.
COMMUNIT Y AT THE HEART This interview was conducted with Ngo anh Dung, Head of the Fundamental Traditional Medicine Department, Faculty of Traditional Medicine, University of Dr. Ngo anh Dung Medicine and Pharmacy, Ho Chi Minh City. Some of his tasks in the community are to take care of patients, to evaluate the community’s health needs, and to educate the community about medicinal herbs and hygiene.
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References AMERICAN ASSOCIATION OF COLLEGES OF NURSING (1999). Distance technology in nursing education (White Paper). HUANG, U. (2002). Toward constructivism for adult learners in online learning environments. British Journal of Educational Technology, 33(1), 27-37. MCKEACHIE, W.J. (2002). In: W.J. McKeachie (Ed.), Teaching tips: Strategies, research, and theory for college and university teachers. Boston New York: Houghton Mifflin Company. OBLINGER, D. & OBLINGER, J. (2005). Educating the net generation. Electronic: www.educause. edu/educatingthenetgen/: Educause. WEIMER, M. (2002). Learner centered teaching. San Francisco, CA: Jossey-Bass.
COMMUNITY INTERVIEW
If you were in charge, what changes would you make in the relationship between the Faculty and community? I would train community members to help themselves, and then pay them a salary.
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STUDENTS’ COLUMN OUT OF THE SNO PEN
INTERNATIONAL DIARY
Sharing Diary 2005 in Atlanta
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“Share, compartir, partager” is a strong idiom: learning and teaching becomes a part of you. In the end, we leave with a piece of everyone inside of us, and that is knowledge that lasts forever. That was, in a nutshell, the main idea surrounding SNO this year. In the 2004 Conference we wanted to make the student voice a more participative one.
Ms. Carole Demosthene That is why we organised a Student Poster Session where all the students presented their posters. There we could perceive each participant’s major ideas, and how they put them on track. We also discussed scheduling a student-mentor rendez-vous to continue the mentor programme. And we planned making an SNO agenda to include sessions featuring educational concern for students. We did not forget that the Conference was not just about learning, but also about having fun, so we designed a ‘cultural session’ to incorporate wider themes: from educational and healthcare programmes, to pastimes or habits. Additionally, to overcome every obstacle, three ambassadors where chosen to strengthen internal links during SNO’s most fragile moments. With these tools in hand, we look forward to support from The Network: TUFH, to attend the Vietnam Conference, and - most of all - to be friends, as this experience is a gift we take with us for life. For more information, check out our website at: www.the-networktufh.org/about_us/sno.asp Carole Demosthene | SNO regional representative, Mexico Email: caquetzal@hotmail.com
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30 August - 3 September, 2005, Amsterdam, the Netherlands AMEE annual meeting. Organised by the Association for Medical Education in Europe. Further information: Internet: www.amee.org 14 - 17 September, 2005, Kraków, Poland 17th Annual EAIE Conference. Organised by the European Association for International Education. Further information: fax: 31-205254998; email: eaie@eaie.nl; Internet: www.eaie.org/krakow/ 25 - 28 September, 2005, Lahore, Pakistan 23rd International Conference on Tuberculosis and Lung Diseases Eastern Region. Organised by Pakistan Anti TB Association. Further information: Pakistan Anti TB Association, 16-K, Gulberg 3, Lahore, Pakistan; tel: 92-42-5756986; fax: 92-425755068; email: pata@brain.net.pk; Internet: www.patba.com 1 - 5 October, 2005, Vancouver, Canada International Indigenous Conference. Organised by the International Network of Indigenous Health Knowledge and Development. Further information: fax: 61-7-47816171; email: internationalnihkd@jcu.edu.au 17 October - 11 November, 2005, Bangkok, Thailand 15th International STDs/ AIDS Diploma Course. Organised by Consortium of Thai Training Institutes for STDs and AIDS (COTTISA). Further information: COTTISA, c/o Bangkok Hospital, 189 Sathorn Road, Bangkok 10120, Thailand; fax; 66-22863013; email: verapol.c@psu.ac.th; Internet: www.cottisa.org 3 - 5 November, 2005, Vancouver, Canada International Conference: Where’s the Patient’s Voice in Health Professional Education. Organised by the University of British Columbia, Vancouver, Canada.
Further information: fax: 1-604-8755611; Internet: www.health-disciplines.ubc.ca/dhcc 4 - 9 November, 2005, Washington DC, United States of America AAMC (Association of American Medical Colleges) annual meeting. Organised by Association of American Medical Colleges. Further information: Internet: www.aamc.org 5 - 9 November, 2005, New Orleans LA, United States of America APHA (American Public Health Association) annual meeting. Organised by American Public Health Association. Further information: Internet: www.apha.org/meetings/ Annual International Conference of The Network: Towards Unity for Health 12 - 17 November, 2005, Ho Chi Minh City, Vietnam International Conference on Making Primary Health Care Work: Challenges for the Education and Practice of the Health Workforce. Organised by The Network: TUFH and the University of Medicine and Pharmacy at Ho Chi Minh City Post-Conference Excursion on CommunityBased Health Professions Education 18 - 20 November, 2005, Can Tho, Vietnam Organised by The Network: TUFH and Can Tho University Further information: Network: TUFH Office, P.O. Box 616, 6200 MD Maastricht, the Netherlands; tel: 31-43-3881524; fax: 31-43-3885639; email: secretariat@network.unimaas.nl; Internet: www.the-networktufh.org/conference/
15 - 18 November, 2005, Bangkok, Thailand 9th International Union against Sexually Transmitted Infections (IUSTI), World
Diary 2006 Congress. Organised by Consortium of Thai Training Institutes for STDs and AIDS (COTTISA) and Department of Disease Control, Ministry of Public Health, Thailand. Further information: COTTISA, c/o Bangkok Hospital, 189 Sathorn Road, Bangkok 10120, Thailand; fax; 66-22863013; email: verapol.c@psu.ac.th; Internet: www.cottisa.org
27 October - 1 November, 2006, Seattle WA, USA AAMC (Association of American Medical Colleges) annual meeting. Organised by Association of American Medical Colleges. Further information: Internet: www.aamc.org/meetings
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31 May - 3 June, 2005, Minneapolis MN, USA Community-Campus Partnerships for Health 9th Conference. Organised by Community-Campus Partnerships for Health. Further information: tel: 1-206-5438010; fax: 1-206-6856747; email: ccphuw@u.washington.edu/ annikalr@u.washington.edu; Internet: www.depts.washington.edu/ccph/
4 - 8 November, 2006, Boston MA, USA APHA (American Public Health Association) annual meeting. Organised by American Public Health Association. Further information: Internet: www.apha. org/meetings/
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21 - 24 May, 2006, New York NY, USA 12th Ottawa International Conference on Medical Education. Hosted by C3NY The Clinical Competence Center of New York and SUNY Downstate College of Medicine, USA. Further information: Mark Swartz, Director, Ottawa in New York 2006, C3NY, POB 4568, Grand Central Station, New York, NY 10163-4568, United States of America; email: mswartz@c3ny.org; Internet: www.c3ny.org
1 - 4 November, 2006, Bangkok, Thailand 9th Asia Oceania Congress of Sexology. Organised by Consortium of Thai Training Institutes for STDs and AIDS (COTTISA). Further information: COTTISA, c/o Bangkok Hospital, 189 Sathorn Road, Bangkok 10120, Thailand; fax; 66-22863013; email: verapol.c@psu.ac.th; Internet: www.cottisa.org
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24 - 29 December, 2005, Ismailia, Egypt 7th Workshop on Human Resources Development in Health Management & Leadership. Organised by Faculty of Medicine, Suez Canal University, Ismailia, Egypt. Further information: fax: 2-643329448; email: crdmed@ismailia.ie-eg.com
6 - 12 March, 2005, Ismailia, Egypt 20th International Workshop on Community-Based Education Incorporating ProblemBased Learning (Innovative Approaches). Organised by the Faculty of Medicine, Suez Canal University, Ismailia, Egypt. Further information: fax: 2-64-3329448; email: crdmed@ismailia.ie-eg.com
Organised by The Network: TUFH and Ghent University, Faculty of Medicine and Health Sciences. Further information: Network: TUFH Office, P.O. Box 616, 6200 MD Maastricht, the Netherlands; tel: 31-43-3881524; fax: 31-43-3885639; email: secretariat@network.unimaas.nl
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28 November - 2 December, 2005, Maastricht, the Netherlands Focused Courses: Assessment Design, Research in Education, Design of an Integrated Curriculum. Organised by Faculty of Medicine, Maastricht University. Further information: Course Secretariat, Office for International Relations, Faculty of Medicine, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands; tel: 31-43-3881524; fax: 31-43-3885639; email: m.senden@oifdg.unimaas.nl; Internet: www.fdg.unimaas.nl/bib/focused_courses
Annual International Conference of The Network: Towards Unity for Health September 9 - 14 2006, Ghent, Belgium
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24 - 25 November, 2005, Maastricht, the Netherlands International Visitors Workshop: A Primer on the Maastricht Approach to Medical Education. Organised by the Faculty of Medicine, Maastricht University. Further information: Workshop Secretariat, Office for International Relations, Faculty of Medicine, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands; tel: 31-43-3881524; fax: 31-43-3885639; email: m.stijnen@oifdg.unimaas.nl; Internet: www.fdg.unimaas.nl/bib/workshop
19 - 22 February, 2006, Dhaka, Bangladesh International Conference: Impact of Global Issues on Women and Children. Organised by State University of Bangladesh (SUB), Dhaka, Bangladesh and McMaster University, Hamilton, Canada. Further information: fax: 1-905-5218834 / 88-02-8123296; email: ic2006@mcmaster. ca / iwc2006@subd.net; Internet: www. subd.net/iwc2006
It is possible to add events to this International Diary from behind your computer. Information inserted in our website database (www.the-networktufh.org) will be automatically included in the International Diary in the Newsletter. 29
MEMBER AND ORGANISATIONAL NEWS MESSAGES FROM THE EXECUTIVE COMMITTEE
General Meeting
2005, Vietnam
The Network: TUFH will organise its annual international Conference this November in Ho Chi Minh City, Vietnam.
According to the new Constitution and By-laws (which can be downloaded at www.the-networktufh.org/about_us/ constitution.asp) not only Full Members but also Associate Members have now the right to vote! The GM and election is an excellent opportunity for your institution to have a voice in who will become part of the Network: TUFH leadership, and in other important issues. We therefore would like to encourage our Full and Associate Member Institutions to send at least one delegate to the Vietnam GM.
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In conjunction with the Vietnam Conference, we will also organise our Biennial General Meeting (GM) for all Network: TUFH members. At this GM three Executive Committee members and a Chairman will be elected.
Elections Executive Committee Two out of seven members of the Executive Committee (EC) complete their 1st term of four years. These members are Rita Goble (United Kingdom) and Lizo Mazwai (South Africa). EC members are eligible for a 2nd term of four years. Rita Goble and Lizo Mazwai will not stand for re-election. Hafiz Al Shazali (Sudan) will complete his 2nd and final term of four years. Of the remaining EC members Ian Cameron (Australia), Laura Feuerwerker (Brazil), and Harsono Mardiwiyoto (Indonesia) are midway through their 1st term of four years, and David Bor (USA) is midway the 2nd and final term of four years. Because of the amalgamation of The Network: Community Partnerships
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for Health through Innovative Education, Service and Research and WHO’s Towards Unity for Health (TUFH) in August 2002, TUFH has selected three individuals to join the EC (for a transition period of three years - ending at the General Meeting [GM] in Vietnam in November this year). After this GM the EC will regain its ‘original’ size of seven members (so that all regions as defined by WHO and The Network: TUFH will be represented), so the term of EC membership for Charles Boelen (France), Pina Frazzica (Italy), and Paul Grand’Maison (Canada) will end in November this year. Also, Fernando Mora (Mexico) will complete his term as Past Chairman. Gerard Majoor (the Netherlands) will end his term of Chairman and becomes automatically the new Past Chairman. The Network: TUFH has three ex-officio members: Michael Glasser (USA) and Margaret Gadon (USA) - Editors Education for Health: Change in Learning & Practice - and a representative of the Student Network Organisation. It is the prerogative of member institutions to nominate candidates for membership of the EC. There will be three vacancies for EC members, including the African, Eastern Mediterranean and European seat, and there will be a vacancy for Chairman. The Constitution of The Network: TUFH says: • Executive Committee (relevant quotes only) Article 8 1. The Executive Committee shall consist of the Officers, and at least five and at most seven members. The Editor of Education for Health: Change in Learning & Practice and a representa-
tive of the Student Network Organisation are ex-officio members of the Executive Committee. 2. The seven members of the Executive Committee shall represent the seven regions of the world: five of which as defined by the World Health Organization: Africa, Eastern Mediterranean, Europe, South-East Asia, and Western Pacific. The Network: TUFH has divided the Americas into two regions: Latin America and USA/Canada. 4. The members of the Executive Committee shall be chosen by the General Meeting and from all members (Article 4.2) for a period of four years. 5. No member shall serve as a member of the Executive Committee in the same role for more than two successive terms. • Elections (relevant quotes only) Article 10 4. The Chairman and the members of the Executive Committee will be elected by the General Meeting. 5. Candidates for election to membership of the Executive Committee must be or represent a Network: TUFH member. We encourage you to stand for election or to nominate candidates for these vacancies. On Tuesday November 15, 2005 at 9.00 a.m. all nominations must have been submitted to the Network: TUFH Executive Director (Pauline Vluggen). A nomination contains a filled in candidate profile form (which can be downloaded at www.the-networktufh. org/conferences/generalmeetings.asp), indicating that (s)he is willing to stand for the position of member or Chairman of the EC. The candidate profile must be signed by the candidate and contain written support from two individuals representing Full or Associate Member Institutions, or who are Individual or Honorary Member. In Ho Chi Minh City, Vietnam, the GM will be split into two sessions, one to be held
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New Executive Director GHETS on Sunday November 13 and the second on Thursday November 17. In the first session of the GM an explanation of the election procedure will be given. Thereafter, but only until Tuesday November 15 at 9.00 a.m., nominations of candidates may still be presented. At the second session of the GM the new EC members will be elected from all the candidates who have been nominated for that position. This round should yield three new EC members and a new Chairman.
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The following criteria for eligibility of the nominee are: • For the last four years (or more) the nominee has participated in Network: TUFH activities, as a leader and as someone who
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Nominations for Tamas Fülöp Award At the occasion of the Network: TUFH’s 25th anniversary, the Executive Committee has installed the Tamas Fülöp Award (TFA). The TFA will be handed out at the General Meeting (GM) to a person/organisation / institution/group for outstanding contributions to The Network: TUFH. This year, at the GM in Vietnam, the first TFA will be handed out.
Honorary Membership Candidates Individuals who have rendered exceptional service to The Network: TUFH can be granted Honorary Membership. We would like to draw your attention to the procedure of proposing candidates for this membership. Any Network: TUFH member can propose candidates for Honorary Membership by writing to the Network: TUFH Office in Maastricht. Nomination proposals must include a letter (300-350 words) explaining the reasons why you support your candidate for the award. The Executive Committee will present the proposals for Honorary Membership to the General Meeting. The decision to award the Honorary Membership shall be taken during that General Meeting, by no less than two thirds of the Full and Associate Members present.
GHETS is a seed funding and programdevelopment partner of The Network: TUFH. GHETS and The Network: TUFH have joined forces to promote strategies for change that address the health related challenges of poor and underserved communities in developing countries. For more information about GHETS’ activities, partners and history, please visit our website at www.ghets.org
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Please do not hesitate to contact the Network: TUFH Office if you need any further information: secretariat@network.unimaas.nl
Nominations for the TFA should be accompanied by a letter of support (300-350 words) and must be received at the Network: TUFH Office no later then September 1, 2005.
Ms. Jessica Greenberg
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Last but not least: in case you get elected, you are expected to attend the first session of the new EC on Friday November 18 in Ho Chi Minh City, Vietnam.
Apart from a certificate, the TFA consists of an economy airplane ticket for travelling to a future Network: TUFH Conference (to be used within three years from the year of award), space in the Newsletter and a world-wide announcement through the digital Alert.
Dear Friends, I am writing to welcome a new Executive Director to GHETS. I have stepped down as GHETS’ Executive Director in mid-May to accept a fellowship at Johns Hopkins School of Public Health. Rachel True will be serving as the next GHETS Executive Director. I look forward to seeing the partnership between GHETS and the Network: TUFH flourish under Rachel’s leadership.
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If you consider to stand for the vacancies in the EC specified above, it would be helpful to know what financial assistance you may expect from The Network: TUFH in order to undertake your responsibilities. EC members from a developing country receive travel (apex) and hotel expenses when attending EC meetings. EC members not from a developing country receive hotel expenses when attending EC meetings.
contributed to The Network: TUFH outstandingly. • The nominee has been relevant to the advancement of health in his/her/its community, country or region in any of the different areas that The Network: TUFH considers crucial (education, professional societies, health delivery, health policy, and community work). • The nominee must be an ethical human being/organisation/institute/group who/ which has had lasting influence on the domain defined under item two.
It has been a pleasure to work with The Network: TUFH and its members over the past few years. Jessica Greenberg | Former Executive Director GHETS, United States of America Email: jessica@ghets.org 31
MEMBER AND ORGANISATIONAL NEWS REPRESENTED AT INTERNATIONAL MEETINGS/CONFERENCES The Network: TUFH is being represented at meetings/conferences all over the world. A report of one of our representatives.
Mounting evidence indicates that primary healthcare teams anchored by generalist physicians are well equipped to deal with frequently occurring illnesses in an equitable and cost-effective manner. Several successful initiatives are ongoing in East and Southern Africa to train district-based primary care physicians, nurses and allied health workers. Many of these projects are supported by North-South partnerships. Effective models of primary healthcare training may be spread within sub-Saharan Africa through linkages between African training programmes and health professions education institutions. A workshop took place in January 2005 in Pretoria, South Africa that allowed key education and health leaders from Southern and East Africa to exchange experiences and explore potential opportunities to form such a collaborative, regional network.
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Brain Drain Sub-Saharan African health systems suffer from pervasive inequities in health services. Skilled health workers are concentrated in urban areas, private health services and in tertiary care hospitals, while a large proportion of the population lives in poor, rural communities. Doctors and nurses work in the context of a globalised labour market, and recent years have brought an acceleration in the migration of health workers from developing to developed countries. This ‘brain drain’ problem is compounded by a number of factors: the status, remuneration and working conditions of doctors in primary care and public service is substantially lower than in tertiary and private care. According to the 2003 World Health Report, the global health workforce crisis is the “most critical issue facing healthcare systems”. It continues: “In most countries,
there will be only small and short-lived advances towards acceptable standards of health without the development of healthcare systems which are strong enough to respond to current challenges”. Consortium Effective primary care workforce solutions in East and Southern Africa require the development and support of healthcare providers with appropriate skills and attitudes to serve local populations. In response to these challenges, eight South African Departments of Family Medicine founded the Family Educational Consortium (FaMEC), to develop post-graduate training for family physicians in primary healthcare in 1997. Since April 2003, the Flemish Interuniversity Council (VLIR) Own Initiatives Project has provided significant support for FaMEC. Family Medicine training complexes have been established in remote and underserved areas and all collaborating departments have co-operated to develop, a ‘corecurriculum in Family Medicine’ with shared didactic and content materials. Training is now organised within the context of primary healthcare in district health systems throughout the country. As part of the VLIR funded project, South-African scholars visited Flanders (Belgium) on ‘training the trainers’ scholarships. It has become clear that neighbouring African countries have similar needs and could benefit from a regional network organised similarly. Meeting in Pretoria For the past two years, GHETS has been working in partnership with Network: TUFH members, universities and physician associations in Uganda, Tanzania and Kenya to develop strategies for improving the training and distribution of primary health-
Workshop participants in Pretoria
care physicians through undergraduate, post-graduate and continuing education. The World Organisation of Family Doctors (Wonca) has identified East Africa as a high priority area and appointed an East Africa Project Manager to work with GHETS as a key collaborator. The Network: TUFH has been a vocal supporter of such training initiatives as well. These developments lead to the January 2005 meeting in Pretoria, attended by trainers and practitioners from eight countries in East and Southern Africa. Workshop participants agreed that there is a strong need for community-based training in primary health in sub-Saharan Africa. The participatory workshop enabled representatives from Uganda, Kenya, Tanzania, South Africa, DRC, Mozambique, Botswana and Zimbabwe to communicate lessons learned and to identify shared challenges they had encountered while establishing district-based Family Medicine training programmes. Participants collaborated to develop a proposal for the establishment of a network of primary healthcare training programmes and training complexes in East and Southern Africa. Furthermore, a group of Ugandan teachers in Family Medicine will be visiting South Africa in May 2005 to learn from the experience of the South African network and the South African Academy of Family Practice/Primary care. This visit, as well as recent exchanges between Makerere University in Uganda and the Faculty of Medicine at the University of Transkei, will contribute to the development of an intra-African Family Medicine network. The Interuniversitary Centre for Vocational Training of General Practitioners (ICHO) FaMEC project was the primary sponsor of
TASKFORCES the meeting. The University of Pretoria and GHETS also provided support for the meeting. Jessica Greenberg and Jannie Hugo | Former Executive Director GHETS, United States of America; Associate Professor, Department of Family Medicine, University of Pretoria, Republic of South Africa Email: jessica@ghets.org; jh38@mweb.co.za
The learning package, using problem-based instructional design, includes instructions for use of the modules, case studies, suggested teaching methods and evaluation/ feedback forms. Users are encouraged to adapt the modules to their national and local priorities.
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Barbara Hatcher | American Public Health Association, United Statesof America Email: barbhatcher@att.net
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However, the Learning Package does not provide enough support to the trainer/ mentor or the self-learner. As currently designed the Learning Package assumes that the trainer who uses these modules has some knowledge of adult learning; instructional experience; personal competencies such as effective communication; and computer skills. It also assumes that the selflearner is motivated and has access to experts with whom they can interact. It also assumes that there are world-wide similarities in educational practices and the worldview of learning. The Learning Package is in English. Since e-
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The Learning Package is a flexible, learnercentred, and economically feasible tool that emphasizes learning by doing. The Learning Package gets high marks (A+) for its relevance, usefulness, real-time learning emphasis; accessibility, and applicability to global communities. The inclusion of the well-constructed feedback forms for the trainer and learner is significant and will go a long way towards ensuring future success. These forms emphasize two dimensions of effectiveness: customer satisfaction and curriculum quality.
learning can require a paradigm shift on the part of both the trainer and learner, the Learning Package and marketing material should make a compelling case for its instructional design and pedagogies and for e-learning. The authors’ biggest challenge is to turn English-language training materials into culturally sensitive, intellectually stimulating and appropriate materials for non-English speakers. While the call for interested parties to submit translated documents is a plus, the authors must ensure that there is a careful translation of their work. What does it take to provide flexible learning environments world-wide? According to e-learning innovators, stories, simulations, goals, practice, fun and failure are the pivotal elements of a successful e-learning system. This Learning Package has the great potential of evolving into a world-class, lifelong, learning community or global village with the help of experts and educators from across the globe. The next iteration of the Learning Package should not only expand its content, technologies, and multilingual format but also its ability to evaluate learning effectiveness using dimensions to identify and describe the participants who were the most successful and to determine users’ Reaction, Learning Achievement, Behaviour, Results; and Return On Investment.
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Name Change for Taskforce Work within The Network: TUFH has continued over the last five years to ensure debate with regard to the implementation of Multiprofessional Education (MPE) and Interprofessional Education (IPE). More recently a taskforce (named Multiprofessional Education) has been developed to review the literature and make recommendation to the Network: TUFH Executive Committee. In doing so, the taskforce not only recognises the many references to IPE in the original paper but also numerous publications which attempt to define MPE and IPE, including Barr (2000) who indicates that IPE “denotes occasions when two or more professionals learn from each other about each other in order to cultivate collaboration and professional insights”. IPE more accurately describes the activities which The Network: TUFH wishes to promote and would seem to be the term of preference to take the work of the taskforce forward. The Network: TUFH has consulted its multiprofessional education listserv members on a name change, and the ones that have responded have done this in a very enthousiastic way in favour of changing the taskforce name from Multiprofessional Education into Interprofessional Education. The name change has been approved by the Network: TUFH Executive Committee. It is recognised that the term used by the European Network for Multiprofessional Education and the World Health Organization (WHO) was Multiprofessional.
THE WO MEN AND HEALTH LEARNING PACKAGE: A REVIEW The Women and Health Learning Package (WHLP) is a free e-learning tool designed to help global communities improve health workers’ training in women’s health. The WHLP is a dynamic or ‘living’ document that currently consists of 5 easy to read learning modules on the following topics: Adolescent Health; Contraceptive Practices; Gender & Health; Unwanted Pregnancy & Unsafe Abortion; Violence Against Women.
The learning package is available online (www.the-networktufh.org/publications_ resources/trainingmodules.asp) and in CDROM format (request a free copy by contacting GHETS, 8 North Main Street, Suite 404, Attleboro, MA 02703, USA). 33
MEMBER AND ORGANISATIONAL NEWS RE-ASSESSING FULL MEMBERS Since 1998 Full Member Institutions (FM) are being re-assessed on a regular basis. As part of this re-assessment procedure FM perform a self-evaluation report. In this section you find summaries of self-evaluation reports. The FM in question have recently been awarded continuation of their Full Membership.
“To Be a Centre of Excellence ”
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Our College of Medicine, established in 1977, is located in Ilorin (North Central area of Nigeria).
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After 27 years as a Faculty of Health Sciences, our Medical School was upgraded to a College of Medicine on the 1st of April 2004 with the 10th Dean, Dr. Ayo Soladoye, as the Acting Provost. In this new status, the College will continue actively in The Network: TUFH. The College is well known for its medical programme, which has produced 1,954 doctors. In addition, there are B.Sc. Anatomy, Physiology programmes. Furthermore, there are postgraduate programmes such as MPH (Public Health), MD (Medicine) and M.Sc., Ph.D. in Physiology, Microbiology and Parasitology. Our mission is “to be a centre of excellence in community-based medical education for the training of doctors who can work anywhere in Nigeria and the world at large.” Educational Programmes This mission statement is the force behind our celebrated Community-Based Experience and Services (COBES) programme. COBES is the hallmark of our medical education philosophy. With COBES we try to produce doctors who are sensitive to community health needs and capable of working in any community through team spirit and scientific principles in solving community health problems. COBES postings are undertaken at 200, 300, 500 and 600 levels, so that medical students spend 20% of their time in the community. Students are also introduced to the community from the first year in the College.
The contents of the educational programmes are oriented to the priority health problems of our country. This orientation is seen in the core clinical programmes and in our special COBES programme. The health problems of the country are mainly those commonly seen in developing countries and these problems are due to malnutrition,
Government (in areas as Disease Surveillance and Control of Communicable Disease) and with other medical schools (assisting in establishing COBES in their school). The strength of our programmes is derived from the community, which requires active collaboration with all stakeholders in the
Medical students attending COBES posting at a community health centre parasitic infestation and infections (bacterial and viral). Therefore programmes address adequately topics like nutrition, anaemia, maternal and child Health, malaria, filariasis, tuberculosis, trauma, and HIV/AIDS. In addition diseases associated with neoplasm, degenerative conditions and Sickle cell disorders are well covered. Linkage and Collaboration The College was designated WHO Collaborating Centre in 1991 and is a longstanding member of The Network: TUFH. Linkages also exist with medical schools within our country, and in Africa and North America. Students visit regularly for elective postings. As a WHO Collaborating Centre, the College has collaborated effectively with the State
health industry. Accordingly, the College has established committees, which include representatives from our immediate environment, the teaching hospital, as well as local and State Government officials. These interactions have made collaboration easy with all stakeholders in the healthcare industry. The net outcome of these efforts is that the community assists with logistic support (e.g. accommodation for our students and transport facilities). Without such effective collaboration the programmes would have been terminated. Our collaboration also motivated other stakeholders to either start a health project or complete an abandoned project. Ayo Soladoye | Provost, College of Medicine, University of Ilorin, Nigeria Email: ayosoladoye2000@yahoo.com
ABOUT OUR MEMBERS
Hubbard Award
for Cees van der Vleuten
It is with pleasure that we would like to inform you that the following Full Members have been awarded a continuation of their Full Membership up to 2010:
Baqai Medical College, Baqai Medical University, Karachi, Pakistan
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STUDENT S HONOUR Åke Wasteson, Vice Rector Student Affairs/ Quality Assurance at Linköping University, Sweden was honoured by his students with the award for University Profile of the Year 2004. According to the students, Dr. Wasteson was awarded this prize “for his sense of humour, for the way he cares about the students, and for being so generous with himself”.
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This continuation has been based on a selfevaluation report and an assessment by an external reviewer. For self-evaluation reports and the reports of the external reviewers, please visit www.the-networktufh.org/ home/membership.asp (mouse click Full membership / List of Full Members).
MOVING ON: CHANGES IN LEADERSH I P The Secretariat received information about changes in leadership with the following Network: TUFH members. We have listed the names of the former and new (Vice-) Deans/ Directors for you: • Dr. Angeles Tan Alora, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines has been replaced by Dr. Rolando Lopez • Dr. Marlene Viljoen, Faculty of Health Sciences, University of the Orange Free State, Bloemfontein, Republic of South Africa has been replaced by Dr. Anita van der Merwe
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B.P. Koirala Institute of Health Sciences, Dharan, Nepal
Dr. Cees van der Vleuten holding his acceptance speech
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Ziauddin Medical University, Karachi, Pakistan
The National Board of Medical Examiners – the national board for certified medical doctor examinations in the USA – awards a biennial prize (the John P. Hubbard Award) to individuals who have made a significant contribution to the assessment of professional competency and educational programme development at any level along the continuum of medical education and delivery of healthcare. The Hubbard Award was established in 1983 as a tribute to the late John P. Hubbard, chief executive of the National Board for 25 years. Cees van der Vleuten (Chair of the Department of Educational Development and Research, Faculty of Medicine, Maastricht University) has been selected as the recipient of the 2005 Hubbard Award. On March 31 he was given the award at the Annual Meeting of the National Board, only the second time in the history of the Hubbard Award that the prize was awarded to a scientist outside the USA. The selection of Van der Vleuten to receive this award is a well-deserved personal tribute in recognition of his contributions to improving the quality of medical evaluation and his international reputation as a researcher and scholar of the highest order. Van der Vleuten’s career has been one of pioneer, substantial investigator, respected and revered scholar and mentor, active collaborator, and consummate speaker. He is noted for his mentorship of hundreds of students to advance their careers in education research and his leadership of one of the largest offices of medical education in the world, where development of the ‘progress test’ has enabled regular monitoring of knowledge acquisition by medical students throughout their curriculum without interference with their learning programme. In addition, his high standards and prolific record of research and education attest to his outstanding abilities and dedication, with over 150 published articles in the field of assessment.
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MEMBER AND ORGANISATIONAL NEWS ABOUT OUR MEMBERS
New Members
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Full Members • Facultad de Medicina, Fundacion Universitaria San Martin, Bogotá, Colombia • The Institute of Health Studies, Barcelona, Spain Associate Members • Ms. Flavia de Freitas, Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, Brazil • Dr. Shahid Hassan, School of Medical Sciences, University of Sains Malaysia, Kubang Kerian, Kelantan, Malaysia • Mr. Willem Dassen, Faculty of Medicine, Maastricht University, Maastricht, Netherlands • Dr. Kevser Vatansever, Faculty of Medicine, Ege University, Izmir, Turkey • Ms. Julie Schurgers, Chainama College VVOB, Lusaka, Zambia Membership Alternation From Associate Member to Full Member • Facultad de Medicina, Universidad de la Sabana, Chia, Cundinamarca, Colombia • Kasturba Health Society, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India • Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, USA Membership Expirations Full Member Institutions • Centre for Medical Education (CME), Dhaka, Bangladesh • Xi’an Medical University (XMU), Xian, Shaanxi Province, People’s Republic of China Associate Member Institutions • Faculdade de Medicina, UNESP - Campus de Botucatu, Botucatu, Brazil • Facultad de Salud Pública, Universidad del Valle, Calí, Colombia • First Faculty of Medicine, Charles University, Prague, Czech Republic • Faculty of Medicine, University of Witten/ 36
It is with pleasure that we would like to inform you that the following Full Members have been awarded a continuation of their Full Membership up to 2009: Herdecke, Witten, Germany • Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India • Isfahan University of Medical Sciences, Isfahan, Islamic Republic of Iran • AMREF Training Centre, Nairobi, Kenya • Medical Center Foundation Phils., Community Paediatrics Society of the Philippines, Ermita Manila, Philippines • School of Physiotherapy, Kilimanjaro Christian Medical Centre (KCMC), Moshi, United Republic of Tanzania Individual Members • Dr. Zafarullah Chowdhury, Gono Shasthaya Kendra, People’s Health Centre, Dhaka, Bangladesh • Dr. Dragica Bobinac, Faculty of Medicine, University of Rijeka, Rijeka, Croatia • Mrs. Sanober Janvekar, International Medical Students Association, Hradec Kralove, Czech Republic • Dr. David Nii-Amon-Kotei, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana • Dr. Rajaratnam Abel, Rural Unit Health & Social Affairs, Ruhsa Campus, North Arcot District, Tamil Nadu, India • Mr. Dhruv Mankad, VACHAN - Voluntary Association for Community Health & N., Nasik, India • Dr. Sukhbir Singh, Chandigarh, India • Mr. Gabriel Aremo Ade, Warri Clinic, CARES - Centre for Adolescent Research, Education and Sexuality, Warri, Delta State, Nigeria • Mr. Babajide Adefemi Alalade, College of Medicine, The University of Lagos, Agege, Lagos, Nigeria • Dr. M.C. Asuzu, College of Medicine, University College Hospital, Ibadan, Nigeria • Dr. M.T. Labinjo, Maritol Medical Centre, Lagos University Teaching Hospital, Surulere, Lagos, Nigeria
Faculty of Medicine, University of Helsinki, Helsinki, Finland Medical School, University of Ghana, Accra, Ghana
Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
College of Medical Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria
Faculty of Health Sciences, University of Ilorin, Ilorin, Nigeria
Membership Withdrawals Full Member Institution • Faculty of Medicine, University of Tromsø, Tromsø, Norway
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Individual Members • Dr. Bisan Swarup Garg, Kasturba Health Society, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India • Ms. Birgitta Lorentzson, Vårdcentralen i Skäggetorp, Linköping, Sweden • Dr. Khalid Bashrahil, Faculty of Medicine, Hadhramout University, Mukalla, Hadramout, Yemen
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South Africa • Mr. Maha Abdelgayoum Hassan Ali, Dhahran, Saudi Aramco, Saudi Arabia • Prof. Christine Nu Viet Vu, Faculté de Médecine - CMU, Université de Geneve, Geneva, Switzerland • Dr. Rosemary Tope, HERC Associates, Cardiff, Wales, UK • Dr. John Conway, College of Health Sciences, The University of Texas at El Paso, El Paso, TX, USA • Dr. William Holzemer, School of Nursing, University of California, San Francisco, CA, USA • Dr. Daniel Korin, Bronx, NY, USA • Dr. Homira Nassery, Health and Population Advisory Service, The World Bank, Washington, DC, USA • Dr. Pablo Pulido, Carretera Via el Altillo, Centro Médico, FEPAFEM/PAFAMS, Caracas, Venezuela
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• Mr. Salako Dokun Matin, College of Medicine, University of Lagos, Lagos, Nigeria • Dr. Okoro Ngozi Menwa, Teaching Hospital, Lagos University, Lagos, Surulere, Nigeria • Dr. Dorothy Nnenna, Human Rights Union for Medical Action in Africa (HURUMA), Ikoyi, Lagos, Nigeria • Dr. Nkata Chuku Nwani, Nigerian Army Reference Hospital, Apapa, Lagos, Nigeria • Dr. Oye Olanrewaju, College of Medicine, University of Lagos, Port-Harcourt, River State, Nigeria • Dr. Philip Onu, Enugu State University of Science and Technology, Enugu State, Lagos, Nigeria • Dr. Tajudeen Oyeyemi Oyewale, College of Medicine, University of Lagos, Lagos, Nigeria • Mr. Sefunmi Savage, College of Medicine, University of Lagos, Lagos, Nigeria • Dr. Yousef Ahmed Al-Weshahi, Accident & Emergency Department, Sultan Qaboos University Hospital, Al-Khoud, Oman • Ms. Ronak Iqbal, Ziauddin Medical University (ZMU), Karachi, Pakistan • Dr. K. Tamayo, Rehab Med, University of Perpetual Help System-Medicine & Health Sciences, Binan, Laguna, Philippines • Prof. Nuno Rodrigues Grande, Instituto de Ciencias Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal • Ms. Gail Andrews, Pretoria, Republic of South Africa • Ms. Joan Littlefield, Management Sciences for Health, HSDUNetworc Education Project, Bisho, Republic of South Africa • Dr. D.R. Prozesky, Faculty of Medicine, University of Pretoria, Pretoria, Republic of South Africa • Dr. Keith Smith, Faculty of Medicine, Medical University of South Africa, PO Medunsa, Republic of South Africa • Mr. G.S. Weir, Faculty of Health Sciences, Medical School, Cape Town, Republic of
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MEMBER AND ORGANISATIONAL NEWS ABOUT OUR MEMBERS Occasionally the Network: TUFH Alert is being used for members (or Network: TUFH relations) who are asking for help from the Network: TUFH membership. Here we give you the results from these ‘quests’. Anselme Derese and Sara Willems from Ghent University were looking for a specific attitude scale.
Members Helping Members Dear reader, Innovative curricula intend to focus more on developing positive community-oriented, preventative and culturally open attitudes. Could any of the Network: TUFH members indicate us an attitude scale (list of statements to score on a Likert scale), which has the potential to differentiate one of those attitudes between groups of students (magnitude about 100 - 150students)?
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Anselme Derese and Sara Willems | Director, Unit for Education Development, Faculty of Medicine Dr. Anselme Derese and Health Sciences, Ghent University, Belgium; PhD Researcher, Department of Family Medicine and Primary Health Care, Ghent University, Belgium anselme.derese@ugent.be
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Sara Willems, MSc
Dear Network: TUFH members, We have a national study (17 medical schools, four years, cohort, three time points, 80% response rate) of US medical students. It includes 12 pages of questions on the prevention-related issues raised by Dr. Derese, as well as many other items. The bottom line of our work is this: there is a strong and consistent relationship between doctor’s personal health practices and their patient counselling practices (i.e., docs preach what they practice), and we can capitalise on this finding by creating healthier medical school environments (which produce healthier medical students who are more likely to counsel their patients). Dr. Derese, we’ll send you a copy, and we’d be pleased to do likewise for others interested in these issues/collaborating. Erica Frank | Vice Chair, Division Chief and Associate Professor, Department of Family and Preventive Medicine, Emory University School of Medicine, United States of America efrank@emory.edu
Dear Anselme Derese, You can find a useful resource in the following web link: www.tolerance.org/hidden_bias/ You need access to computers so your students can take the tests online. Francisco Lamus | Professor, Salud Pública y Proyección Social, Facultad de Medicina, Universidad de La Sabana, Columbia francisco.lamus@unisabana.edu.co
Hello Dr. Derese, One of the instruments that I think might be worth considering was developed by Arthur Rothman and J. Parlow and reported in the literature. In 1974 - Attitudes towards Social Issues in Medicine. Arthur Rothman remains active in medical education research and as of 2000 was at the University of Toronto, Canada. The questionnaire is administered anonymously, and includes multiple subscales, and has been validated. It includes a scale for Social Desirability - allowing the researcher to check the degree to which the respondents are answering inauthentically - usually providing answers to please the researcher.
Articles about the ATSIM: PARLOW, J. & ROTHMAN, A. (1974). ATSIM: A scale to measure attitudes toward psychosocial factors in health care. Journal of Medical Education, 49(4), 385-7. PARLOW, J. & ROTHMAN, A. (1974). Attitudes towards social issues in medicine of five health science faculties. Social Science and Medicine, 8(6), 351-8. Hope this is somewhat on target for the request. Sincerely, Summers Kalishman | Director, Office of Program Evaluation, Education and Research, University of New Mexico School of Medicine, United States of America skalish@salud.unm.edu
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Dear Anselme, In response to your request via The Network: TUFH for an attitudinal questionnaire, I would like to share the following information: • I conducted research a number of years ago to determine the attitudes and opinions of pharmacy students from two universities where traditional and innovative curricula were taught respectively, • a five point Likert scale was used to assess 11 questions determining attitude; • the questionnaire furthermore consisted of a biographical section in which the area where students have spent their teenage years were determined, e.g. in a rural or an urban area; a section in which students were asked to indicate why they have studied pharmacy; what their preferences were in terms of the various areas in which they could work (community, hospital, industry), their approach towards community service were tested and a last section where their opinion on their learning experience were determined; • a rationale for each of the questions is available, should you be interested.
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Dear Anselme, For reasons I would love to explain at another occasion I have on my desk a paper by Karen van der Zee and Jan Pieter van Oudenhoven, titled The Multicultural Personality Questionnaire: A Multidimensional Instrument of Multicultural Effectiveness. European Journal of Personality 14 (2000) 291-309. Perhaps that paper may partly answer your question. Feel free to ask me to send you a hard copy if you have no access to that journal.
Please inform whether this would be of any use and I will gladly forward the questionnaire and rational statement if needed. Kind regards, Mariëtte Lowes | Dean, Faculty of Health Sciences, Tshwane University of Technology, South Africa lowesmmj@TUT.ac.za
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MEMBER AND ORGANISATIONAL NEWS
I N T E R E ST I NG INTERNET SITES The Network: TUFH Interactive - Recommended Internet sites www.the-networktufh.org/publications_resources/interactive.asp New Online Tool Kit on HIV/AIDS Prevention for Sex Workers www.who.int/hiv/toolkit/sw Building Partnerships for Public Access to Research. The International Science Shop Network www.scienceshops.org/
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Theme issue of the Journal of Continuing Education in the Health Professions. The articles cover important perspectives including demography, education, licensure, and ethics of physician migration www.jcehp.com/vol25/2501_norcini.asp Warning over Healthcare Migration news.bbc.co.uk/2/hi/health/4535805.stm Equality and Diversity Impact Assessment Toolkit www.scotland.gov.uk/library5/health/eqdiat-00.asp
THE NETWORK TOWARDS UNITY FOR HEALTH
Newsletter Volume 24 | no. 1 | June 2005 ISSN 1571-9308 Editors: Marion Stijnen and Pauline Vluggen Language editor: Sandra McCollum The Network: Towards Unity for Health Publications P.O. Box 616, 6200 MD Maastricht the Netherlands Tel: 31-43-3885633, Fax: 31-43-3885639 Email: secretariat@network.unimaas.nl www.the-networktufh.org Lay-out: Graphic Design Agency Emilio Perez Photograph on page 22 courtesy of Sardjito Hospital – Faculty of Medicine, Gadjah Mada University Photograph on page 35 by Eva Bergstedt Print: Drukkerij Gijsemberg
Reducing Health Disparities: What Is Being Done, What Works www.cdc.gov/pcd/issues/2005/apr/05_0002.htm The designations employed and the presenta-
John Hamilton Delivers Network: TUFH Lecture
tion of the material in this newsletter do not imply the expression of any opinion whatsoever on the part of the World Health Organization and The Network: TUFH concerning the legal status of any country, territory, city or area or
At the occasion of the biennial General Meeting of The Network: TUFH, one of our distinguished colleagues is being given the opportunity to deliver the ‘Network: TUFH Lecture’. By inviting Dr. Hamilton to present the Lecture, The Network: TUFH pays tribute to him for performing extraordinary work in line with the aims of The Network: TUFH. Dr. Hamilton will deliver his speech on The Job We Have: Thinking Globally, Acting Locally. Dr. Hamilton is Academic Director of the Pre-Clinical Curriculum at the University of Durham, Queen’s Campus, at Stockton-on-Tees, UK.
of health professionals, administrators and policy makers focusing on health priorities. Dr. Hamilton’s interest in the integration of medicine and public health, the numerous positions he has held in academic institutions and health services organisations in various places in the world, and his strong interest in health research make him the perfect key speaker at our General Meeting.
of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization or The Network: TUFH in preference to others of a similar nature that are mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization and The Network: TUFH do not warrant that the information
The Network: TUFH over the last decade has emphasized (next to reorientation of health professions education) the creation of functional partnerships between communities, academic institutions, organisations 40
contained in this newsletter is complete and correct and shall not be liable for any damages incurred as a result of its use. Any named authors are responsible for the
Dr. John Hamilton
views expressed in their signed articles.