NEWSLETTER Newsletter Volume 31/no. 1/June 2013
Editorial Dear Readers,
In this issue, among others:
Our annual conference, this year held in wonderful Thailand is approaching so time for a new newsletter!
• Timothy Evans
In this newsletter we focus on health professionals recruitment and inequity. You can read on p6 about a South African initiative or p 18 on the situation in Nepal. On p13 we talk about the development of the Sudan Family Medicine Project.
• The Beyond Borders Initiative • Leadership Column: Roger Strasser • EC Eminence:
We would also like to draw your attention to the birth of a new taskforce, “Implementation of Transforming Health Professionals Education and Training Guidelines” Read more p 27 Keep on networking, that’s what The Network: TUFH is all about! Let this newsletter be your platform to connect and communicate!
John Hamilton
Enjoy your reading!
Julie Vanden Bulcke, Editor
In the Newsletter we refer to The Network: Towards Unity for Health as The Network: TUFH.
Contents Message from the Secretary General 3 Networking with Networks...
The Network: TUFH in Action 4 Annual International Conference 4 Annual International Conference 5 Education for Health
Looking forward to Thailand Exclusive Preview of 2014 Brazil Conference Update
Improving Health 7 8 8 10 11 12 13
Health Promotion Women’s Health Health Prevention Health Research Rural Health Great Stories from Great People Great Stories from Great People
Addressing Inequality in Access to Healthcare for South Africa’s Rural Poor The Experience of Sexual Assault Survivors in a South African Community The Effect of the MU Health Caravan W.E.A.L.T.H. Upcoming Global Mulidrug-Resistance Participatory Need Assessment Workshop as a Method to Empower Women Timothy Evans Khalid Gaffer Mohamed: Scaling Up Capacity for Family Medicine in Sudan
International Health Professions Education 14 15 16 17 18 19 20 21 22 23
Medical Education Medical Education Medical Education New Institutions and Programs New Institutions and Programs PBL and Community-based Education PBL and Community-based Education Distance Learning Interprofessional Education Leadership Column
Training Program for Chinese Rural Practitionars Based on Low-Cost Health Care The Beyond Borders Initiative Barriers and Facilitators for Canadian Aboriginal Students in Medical School Access Rural Medical Scholars Program Selecting Medical Students to Help Address Rural-Urban Physician Maldistribution Teaching Final Year Medical Students in the Community Go Global Program Perth Using Information Technology in Health Professional Education How to Prepare Future Healthcare Professionals Roger Strasser
The Like-Minded Working Together 24 THEnet
Joining Forces for Greater Impact
Student’s Column 25 Out of the SNO Pen 25 Students’ Interview
Sawasdee! The Big Five
Member and Organisational News 26 27 28 28 29 30 31 32
Message from the Executive Committee Taskforces Taskforces Taskforces Taskforces Taskforces Education and Research Introducing Members
EC Eminence: John Hamilton WHO Guidelines Updates from the Women and Health Taskforce Interprofessional Education Social Accountability and Accreditation Integrating Public Health and Medicine The Wall of Fame New Members
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Message from the Secretary General Networking with Networks…. The Thunder Bay 2012 conference has been the starting point for a new phase in the development of The Network: Towards Unity for Health. The phase of: Networking with networks. The Thunder Bay-conference gave us the opportunity with like-minded organizations, to share experiences, and to look forward for common strategies. A first opportunity is related to the contribution that Dr. Erica Wheeler, WHO Geneva, made at the conference. She outlined the process of the World Health Organization-Geneva-office in building guidelines on medical education: ‘transforming and scaling up health professions education and training’. The networks and organizations, represented at the Thunder Bay-conference (The Network: Towards Unity for Health; the Consortium of Longitudinal Integrated Curricula; Flinders University; Northern Ontario School of Medicine; THEnet: Training for Health Equity network; the WONCA Rural Working party…) agree to respond positively to the invitation of Dr. Wheeler, to engage in a process on implementation of these guidelines. As the Network: TUFH, is an organization in and official relationship with WHO, “open” taskforce was created within the Network, in order to link the inputs of the different contributing organizations with the WHO-office. This taskforce on “implementation of transforming health professionals education and training guidelines”, is open to the membership of the Network: TUFH. Please contact the secretariat if you want to be linked with this taskforce.
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The taskforce is chaired by Sue Berry (NOSM). This is a great opportunity for the membership of the Network, to bring to the debate the experiences that many of us have built on during the last 3 decades. In the meantime, the EC and the secretariat are very active. Under the coordination of our executive director, Maarten Declercq, we had some very interesting EC-skype-meetings. His direct interaction will be intensified in order to make the Network more “active” in-between the annual conferences. We invite you all to send your contributions for the annual conference in Ayutthaya, Thailand, November 16th-20th, 2013. We hope to meet you soon! Prof.dr. Jan De Maeseneer, M.D., Ph.D. Secretary General The Network Towards Unity for Health Email: jan.demaeseneer@ugent.be
The Network: TUFH in action Annual International Conference Looking forward to Thailand We are already there I am convinced that The Network: TUFH is already there. This might seem contradictory in today’s rapid changing landscape where everything seems to be in permanent crisis. However when we take time to stand still and take a long hard look, then we can see through all the motions and see that on a deeper level we are already there. It is completely true that we need to build a sustainable future by consequently taking coherent action every day and that we need all of our courage to keep going. But already at this very moment there is an insurmountable amount of energy present in The Network: TUFH. This playful and light-touch energy can guide us in every single step along the way.
We are looking forward to seeing you at the 2013 Conference in Ayutthaya, Thailand which takes place from November 1620. We will welcome an animated group of familiar and freshly minted faces. The common thread is that everyone is ready for interaction and dialogue. Renewal happens at the borders and this is exactly how we are composing a program that will bring you to new insights. The theme for this year is “Rural & Community-Based Health Care: Opportunities and Challenges for the 21st Century “. Princess Naradhiwas University (PNU) and the College of Medicine of the University of Illinois at Rockford are the co-hosts for this year’s conference. Together we have compiled a set of interesting community site visits which will bring you closer to the Thai communities. For PNU the conference also functions as a celebration of their first batch of medical graduates. Further we will experience the Loi Krathong festival. This is the annual Flower Floating Festival and will makes us all awe and wonder of the beauty of Thailand. The Network: TUFH is already there for you and for your benefit. Let us take the same direction, work together and become stronger. Maarten Declercq, Executive Director, The Network: TUFH Email: maarten.declercq@ugent.be
Exclusive Preview of 2014 Brazil Conference: Interview with Professor Henry de Holanda Campos What ideas do you have about the 2014 conference, what should be the focus? One of the main challenges faced by most of the countries is to educate professionals that fit the needs of the population and of the health systems, so I think that the more we invest in that field, the closer we will get to having universal standards of curriculums and guidelines, to get these professionals that better meet the current needs. It is a very important occasion to gather deans from medical and other health care professionals schools, and discuss different approaches so we can really implement changes. We have a lot of changes still on paper, but which are very hard to become reality. The Network:TUFH conference is the ideal scenario for discussing these things. For sure we have an interesting agenda for 2014!
Health equity although not perfect yet, improved a lot, for people who have no private insurance. Secondly, the structure of Brazil family medicine is very powerful, and I would like to emphasize the need and importance of having a primary care based system. Can you tell us something about the location and the hosts? Fortaleza, a city in the North of Brazil, will be the location of the conference. It is the place where the family health structuring began, so there are a lot of local organizations and initiatives that will be interesting to visit. It is also the fifth largest city in Brazil and very accessible by direct flights. The main host will be the Federal University of Ceara, one of our ten biggest universities with full support of the ministry of education and health. Partners are main educational organizations like “The Brazilian Medical Education Association”.
Can “the Brazil experience” in the last decade be an inspiration for other countries? Can you pick 2 highlights of health system reforms from the last 10 years. First, we advanced a lot in access to health care. Brazil is a good example for a universal system with universal access, as recommended by WHO.
Prof Henry de Holanda Campos, Vice-Rector, Universidade federal do ceara, Benfica, Bresil Email: vreitor@ufc.br 4
The Network: TUFH in action Education for Health Update
It has been a busy and productive year for Education for Health (EfH). Manuscripts keep coming in at a high rate. Plans are in the works for special issues of the journal including such topics as interprofessional education, reflections on last year’s joint conference in Thunder Bay, Ontario, Canada, and medical and health professions programs and research from Portuguese-speaking academics in Brazil. A major event this year was the trip by co-editors Donald Pathman and Michael Glasser to Pune, India to meet the managing editor and production editor and see, first-hand, the new journal home. We visited in late February, arriving in Mumbai and traveling to Pune with Dr. Gaurang Baxi, who is in charge of producing the journal, from handling of submissions of papers to review and actual publication of manuscripts. On the first part of the visit, in addition to discussions between the co-editors, Dr. Baxi, and Dr. Payal Bansal, managing editor of EfH, we had the opportunity to tour the local site of the Maharashtra University of Health Sciences (MUHS), where EfH is managed and produced. The following day, Don and I had the opportunity to meet with Mr. Sunderrajan, representative of the EfH publishing house, Medknow Publications & Media Pvt Ltd. It was a fruitful meeting with our publisher covering such topics as domain name transfer, copyright protocol, print copies of the journal and impact factor. A highlight of the trip was travel to the MUHS home university site in Nashik. For someone in charge of a rural program in the United States, this was an interesting drive seeing the countryside and people between Pune and Nashik. We stayed the night at MUHS allowing time for many discussions and new contacts, including meeting with the Management Council of MUHS and the Vice Chancellor Dr. Arun Jamkar, whose insight and support led to the journal location in Pune. Back in Pune, Drs. Pathman and Glasser conducted two workshops over two days: “Manuscript Writing for Medical and Health Sciences Journals” and “Manuscript Reviewing of Health Sciences Journals.” These provided the opportunity to meet with local and regional faculty and researchers. It was a busy, and productive, visit. And one of the co-editors – whose identity will not be divulged – was completely impressed by the spices (nicely done heat), aromas, and textures of the local cuisine. I’ll conclude this update with a request for more people to sign up as reviewers for EfH. As the journal for Network: Towards Unity for Health, we need your support in helping us decide on what ultimately gets published in your journal! Michael Glasser, Ph.D. Co-editor, Education for Health. University of Illinois – Rockford Email: michaelg@uic.edu
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The Network is all about the People
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Improving Health Health Promotion Addressing Inequality in Access to Healthcare for South Africa’s Rural Poor through Leveraging Multi-Sector Partnerships in the Recruitment of Health Workers Maria’s* 73-year-old uncle suffers from lung cancer. He lives in Qhoboshane, a small village in the Eastern Cape in South Africa where accessing healthcare is near impossible because of the distances patients have to travel. To receive treatment he has to walk 3km to catch a taxi. This takes almost three hours as he needs to stop and rest regularly. His journey by taxi takes almost an hour because of the terrible condition of the roads. When Maria and her uncle finally arrive at a public hospital they stand in a queue for more than four hours. Maria’s story is unfortunately not unique. Millions of South Africans have to travel great distances and stand in long queues to access healthcare. South Africa’s healthcare environment The biggest challenge facing public healthcare is the shortage of healthcare workers. There is an estimated 83 043 shortfall of all health professionals in the country. The majority of South Africa’s public sector doctors work in urban centres. The result is that the deficit in health workers is most severe in rural areas where 43.6% of the country’s population live, but only 12% of doctors and 19% of nurses work. The enormous staff shortages certainly have an impact on the care offered to patients. Doctors and nurses are overworked and burned out. The quality of healthcare that patients receive in urban and rural areas is highly unequal, with urban patients generally being able to access better services. Recruiting healthcare workers through pragmatic partnerships Locally trained resources are insufficient to close the gap. An often dismissed yet indispensable piece in solving the doctor shortage puzzle is the recruitment of foreign-qualified doctors. In South Africa, foreign-qualified doctors come for various personal reasons which include work experience, quality of life, adventure, and philanthropy. Africa Health Placements (AHP), a social profit donor-funded organisation has, since 2005, sourced, recruited and placed 2 500 local and foreign-qualified healthcare professionals in the country’s public healthcare facilities in rural and underserved areas. Recruiting foreign-qualified doctors should not be seen as a short-term solution. Foreign-qualified doctors can aid hospitals in becoming self-sustainable. AHP has developed a recruitment model to assist facilities in becoming self-sustaining. Firstly, effective management has to be in place. Foreign-qualified health professionals can then be recruited. Once a contingent of foreign-qualified doctors is in place, local workers can be attracted more easily. With a team of experienced doctors on board, junior doctors will follow because they have the opportunity to be mentored. Management can then move out of “crisis management” mode and focus on improving quality of care.
The unique filing system at St Lucy’s Hospital in the Eastern Cape
AHP works with its partners to ensure South Africa becomes a competitive destination for the recruitment of these globally scarce and mobile resources. We work with the London GP Deanery and the Australian College of Rural and Remote Medicine. Through these partnerships, medical students who are in the process of specialising come to practise in South Africa’s rural areas. This brings critically needed health workers to South Africa, while simultaneously improving the skills of foreign-qualified doctors. AHP partners with public sector stakeholders through all levels within the health system: from the minister’s office through to provincial health departments, district offices, and hospitals. AHP also works with several statutory councils including the Health Professions Council of South Africa and the South African Nursing Council to ensure the registration process runs efficiently. AHP not only recruits foreign-qualified healthcare workers, but also recruits local professionals and provides HR assistance to the largest PEPFAR funded organisations in South Africa. Partnerships with local universities and medical associations bolster AHP’s database of local-qualified candidates. A cog in a machine The success of AHP’s approach is built on a foundation of innovative and pragmatic partnerships. AHP pulls together all stakeholders from the national Department of Health to rural hospitals to find solutions to complex problems. We are merely a cog in the machine, but we play a vital role in forming partnerships and offering real insight based on practical experience in rural health. *Not her real name Saul Kornik, Chief Executive Officer, Africa Health Placements; Retha Grobbelaar, Media and PR, AHP Email: saulk@ahp.org.za
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Improving Health Health Prevention The Effect of the MU Health Caravan W.E.A.L.T.H. on the Knowledge, Attitude and Practices of the Women of Miagao
Women’s Health The Experience of Sexual Assault Survivors in a South African Community
Introduction In the Philippines, many still hold the view that it is solely or mainly the women’s role to protect themselves and to attend to family and domestic roles and responsibilities. However, herein lies the great irony: with regards to health, women are seen as its promoters and primary caregivers, however, the problems of women are still not well recognized, leading to delays in treatment-seeking and diagnosis
World wide sexual assault affects all classes, races, ages and sexual orientation. In South Africa sexual assault has become a serious crime in medico-legal framework. Rape statistics are not reliable because not all survivors come forward to report cases. The stigma attached to sexual assault makes giving evidence in a court of law a challenge. The perpetrator may be a relative (common is the uncle or the step father or even the father). Protecting family income and culture are also important determinants of failure of prosecutions. It has become important to get first hand information of how survivors felt after the incidence of sexual assault. Expressions of alcohol and drug abuse in order to cope were expressed. Lack of trust and fear of men is a concern to the community as these are people naturally meant to protect the vulnerable groups in society-women and children. Survivors, just like women do in the African contexts, tend to blame themselves unfairly as if they may not go to some places without fear of an indecent assault. In some cases in South Africa women were blamed for wearing short dresses. This resulted at a certain stage a march by women to government offices revolting against insensitivities towards their rights to wearing what they wanted to wear. Gang rape is humiliating enough especially in front of one’s children- what happened to morals? Lately, very old women are sexually assaulted, the latest incidence involving a 92 years old raped by a 23 year old who received parole. There is much to be done to protect the vulnerable members of the community- women and children , and to avail to them post non-judgemental post traumatic counseling .
Recognizing these dilemmas and our duty to promote health and mobilize society to become a part of the solution to these problems, the Sorority developed a Campaign called Women Empowerment and Literacy through Health Education (W.E.A.L.T.H.) which consists of day long lecture series, workshops and a health primer, all done by medical students and doctors. The W.E.A.L.T.H. Caravan hopes that, by being informed, participants will adapt a healthy lifestyle, leading to lesser disabilities and empowering them in raising health awareness. Thus, the target participants were teachers and health workers, who are in the Philippine society considered as resources in disseminating information crucial in achieving wellness within their communities. Moreover, monitoring and evaluation post project implementation is the step often missed out by most project developers, thus, this serves as an exploratory study evaluating the effects of the W.E.A.L.T.H. Caravan on the knowledge, attitude and practice of its participants, specifically the women of Miagao. Method Participants of the study were the attendees of the W.E.A.L.T.H. Caravan in Miagao, selected through convenience sampling.
In conclusion: The experience of rape never goes away. It carries through to the whole life of the survivor. The majority never live to tell their stories. They are buried in shallow graves and are discovered by accident. An injured woman will instill fear on her girl children and the result is a sick society .
Methods used were survey, interview, focused group discussion and written examination. Data were qualitatively analyzed using the grounded theory approach.
Dr john Ndimande, Department of Family Medicine and Primary Health Care University of Limpopo, Pretoria, South Africa Email: ndimande@telkomsa.net
Result Twelve months after, 41 out of 45 participants remembered the W.E.A.L.T.H Caravan.
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Improving Health Health Prevention The Effect of the MU Health Caravan W.E.A.L.T.H. on the Knowledge, Attitude and Practices of the Women of Miagao
It was noted that there is increased frequency of exercises, consumption of vegetables and fruits. It also served as a venue to know the different ways to manage stress. Health screening methods such as the self-breast examination, and medical consultation were already done by most of the participants. In fact, one participant did self-breast examination, felt a lump, subjected herself to consultation, found out it was cancer, immediately underwent treatment and is now declared cancer-free. However, pap smear is still not done because of their fear of doing it. Vaccination for cervical cancer is not carried out due to unavailability of resources or expensive vaccines. Most participants pointed out that they learned much of what they know now from the seminars. Ten participants answered specifically the Mu Health Caravan WEALTH.
The Mu Caravan team in action
programs designed to address these issues in the town, could be of great help.
The W.E.A.L.T.H. Caravan hopes that, by being informed, participants will adapt a healthy lifestyle, leading to lesser disabilities and empowering them in raising health awareness.
Conclusion For most people of Miagao, health is not the top priority. It always comes next to work or education. Coupled with this, are the lack of resources, and easy access to health services, and lack of opportunities to gain knowledge, hinder most of its people into living a healthy lifestyle.
Accommodating and expert lecturers, tailored-fit topics, and the health primer contributed in inculcating the knowledge among the participants. The primer became their reference to answer questions of their colleagues whenever they encounter questions of topics they already forgot.
The current health seeking behaviors of the participants noted to have improved after attending the W.E.A.L.T.H. caravan. They emphasized that with being knowledgeable of things, could lead to having a positive attitude and putting it into practice. The W.E.A.L.T.H. Caravan undoubtedly was seen by the participants as a venue to gain knowledge regarding one’s health. Being women and mothers, participants were able to apply the knowledge gained into their lives and their families’ lives and being teachers and health workers, they were able to share it to their students and members of the community further simulating the ripple effect the creators of the W.E.A.L.T.H. caravan envisions. Certainly, with their help, more people in Miagao was reached and hopefully convinced into living a healthy life.
Participants also have Positive attitude towards the W.E.A.L.T.H. Caravan, undergoing health procedures, and conducting and financing health seminars. Participants reported that they felt empowered living a healthy life and serve as examples in the community after attending the W.E.A.L.T.H. Caravan. However, there are still some who continue to smoke, drink alcohol and eat fatty and salty foods despite knowing its bad effects. Thus, frequent reminder through coming up with health
Marianne Joy Naria, College of Medicine, University of the Philippines Manila Email: marianne.naria@gmail.com
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Improving Health Health Research Upcoming Global Multidrug-Resistance Subsequent to Inappropriate Use and Its Potential Danger Concerning Human Health Care Multidrug-resistance (MR) has scientifically been proven to be globally developed over the past half-century as a result of excessive and inappropriate use of antibiotics. In the European Union, drug resistant infections are estimated to cause more than 25 000 deaths and generate health care costs of 1.5 billion euros annually. Even if MR is a natural biological phenomenon of the response of microbes to the selective pressure of an antimicrobial drug, it is important to do scientific evidence-based research concerning which steps can be taken to prevent or at least delay this process. The sale of antibiotics e.g., without having a doctor’s prescription, is very common in developing countries and results in ‘self-medication’ which has led to an increase in morbidity, mortality and cost of health care. It is a well-known fact that Multidrug-Resistance (MR) has been emerging on a global scale over the past half-century as a result of excessive and inappropriate use of antibiotics. So at a certain moment, we asked ourselves the question which factors influence this kind of increasing and more important, if we can find correlating factors by setting up a survey that give an idea of the general knowledge of people of different ages and from different social classes. Our objectives were to test the impact of MR information and prevention campaigns in multiple layers of society. First of all, you can ask yourself the question what antibiotic resistance exactly means and why is it so dangerous? Basically it all comes down to this: through the use of antibiotics, your body is able to heal when you suffer from a bacterial infection that may lead to an inflammation. But the use of antibiotics is not always necessary, your body heals itself most of the time. However, here lies a problem… not everyone is that patient and the doctor decides to prescribe antibiotics or in some countries, people just buy antibiotics on the street. The consequence of that can be an increase of antibiotic-resistance or MR in general. The reason why antibiotic resistance is dangerous is quite simple; the resistant bacteria themselves are not bounded by any country borders, which leads to the main issue: bacterial resistance on
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a global scale; due to inappropriate prescription. Not only your own health, but also the health of your family, your neighbours, your colleagues, your compatriots… becomes precarious. In an absolute worse-case scenario, we won’t be able to treat certain diseases in the future, because of the increasing MR all around the world. As an example of the main problem, we give you a few facts: the average percentage of patients suffering from MRSA in 2009 (methicilline-resistant Staphylococcus Aureus, well-known as the hospital bacterium) amounts 1-2 percent in the countries in the north, which do not have self-prescription, and 3050 percent in the countries in the south of Europe, such as Portugal, where there is self-prescription. We find it important that we can make people aware of the problematic situation that we are creating nowadays for each other, ourselves and the upcoming generations all over the world. The problem is emerging; a majority of scientists agree with that. But the main issue is that the population has a lack of information about this certain topic, associated with non-effective campaigns. The reason why we designed our own campaign concerning correct use of antibiotics is because when you want to read a leaflet about correct use of antibiotics and other drugs, you have to order it at the federal government in Belgium. So basically, you can’t find any folders in the waiting-room of your doctor, not on billboards on the street, not anywhere… Our main conclusion is that there is a need for global guidelines concerning better diagnosis, rational prescription and customized duration of treatments with antibiotics. This, in turn, may help to control the development and spread of MR and reduce health care costs. Reducing antibiotic self prescriptions can improve the clinical outcomes if both health care workers and patients stick to the program. Stéphanie Raman and Sofie Schietecatte, Medical Students, University of Ghent Email: Stephanie.Raman@UGent.be
Improving Health Rural Health Participatory Needs Assessment Workshop as a Method to Empower Women in Makali Village, East Sudan The participants strongly believe that the community leaders can promote their project proposals. The proposals made by men focused on the infrastructure (water and electricity supply). The impression is that most of the proposals about infrastructure are not feasible. Most of the projects being designed by females have the main aim to educate and empower women in the community, with proposals more feasible.
East Sudan has been affected by conflicts and the infrastructure is underdeveloped. The population is among the poorest in Sudan. The region has one of the highest maternal and child mortality rates in the country. It also has a high number of different tribes and is influenced by strict cultural and traditional values. Makali village is a large rural village in Kassala state. More than one ethnic group is found in Makali. The main income sources are from farming and grazing. On average the socioeconomic status is low to moderate. The village has been exposed to a few community programs from UNICEF who built the health center and PLAN, a Sudan organization that worked with water and sanitation in the village.
participants identify problems in their own village, evaluate them and come up with local solutions by designing their own projects. The final goal is to increase the capacity and empower the women and the community to make its own changes.
The outcomes from this workshop are that the number of females who volunteered to participate in the workshop was twice that of the men. They were more eager to attend and have their voices heard. The female group leaders were assertive and competent; the rest of the women gave their ideas as they felt the importance of their input in identifying the community’s issues. The issues identified and the proposed solutions by the groups led by females were more realistic and feasible.
The participants were chosen after request from two community representatives and the community youth leader. They asked each tribe representative to select participants for their tribe randomly, but with the selection criteria that some women should attend. In the end there were five male participants and In conclusion, this participatory approach was effective in overcoming cultural barriers; The 22 female participants. participants forgot their gender differences A five days participatory needs assessment and focused on identifying issues and their soworkshop was conducted in Makali Village lutions. The groups led by women were able where women and men were brought toge- to identify issues that men were not aware of ther to identify major issues in their village and give more feasible solutions. and possible solutions. The women were encouraged to participate in group exercises Ashraf K. M. Ahmed , Research Fellow, Univerwhere the groups were divided into females sity of Medical Sciences & Technology (UMST), and males. They were probed by the modera- Sudan tors to give criticism to the ideas raised during Email: ashrafkhalid@live.com the discussion. Then they were divided into The participatory need assessment work- mixed groups where half of the groups were shop is a part of the University-Community led by women. Partnership Project (UCPP). UCPP is a partnership between University of Medical Sci- During the workshop the facilitator collected ences and Technology, University of Kassala qualitative data in form of the identified isand a vulnerable community, with the aim sues and issues’ themes. Finally, the top 5 was of improving health through influ¬encing selected. social determinants, and advancing reproductive and child health. Involving the com- The most prioritized issue is the non-functiomunity, em¬powering women through the ning health care system. In Makali village the formation of women groups, and encouraging health center is non-functioning because it’s stake¬holders to focus on both supply and de- understaffed and there are no possibilities for mand side barriers to health are strategies to laboratory investigations, any type of medical promote the development of Makali village. equipment or minor surgery. Access to medical drugs are limited and all emergencies are The workshop focuses on Project Manage- referred to Kassala, which is far and not fully ment tools and capacity building for parti- accessible by paved roads and no means of cipants of a vulnerable community, Makali transportation. village. The aim of the workshop is to let the In the village there is one primary school and one non-functioning health centre. There is no electricity in Makali village but there are electrical generators. The village has a community leadership. It is headed by a leader that is respected by the community and any decision given by him is obeyed. In Eastern Sudan women have a secondary role in decision making with the men being the major decision makers. A woman’s fate is to become married from a young age and bear children. She stays at home to take care of her family and perform various household tasks such as cooking and cleaning. Women cannot speak or give their opinions in front of men leading to them having a diminished role in the community.
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Improving Health Great Stories from Great People Timothy Evans After an inspiring keynote speech at Rendez-vous 2013, we could catch Dr Timothy Evans for a quick interview! Amazing, as he was less then 24hours in Canada. Dr Timothy Evans, currently Dean of BRAC University in Bangladesh, is one of the big specialists in global health with particular focus on health equity, health systems and health research policies. We were delighted to ask him some questions!!
One of your main messages was that public health should be more related to clinical care. How do you see that because of schools of medicine and schools of public health have been separated. Do you agree that there should be more interaction between both? I think there are multiple areas of conversions and I don’t really like to make a distinction because to me they go hand in hand and increasingly. For example, we get excellent information systems through electronic medical records, which is a wonderful area of conversions. But in terms of education around public health there is much demand for that amongst clinicians as there are from other types of non-clinical health workers and so a lot of what we’re talking about in reforming public health education is with a view to engaging people who are trained clinically in that education because we know that in their work and in their day to day jobs they have very important public health functions as part of their role as health workers. When I saw your four D’s and your cycle I actually saw the cycle of Community Oriented Primary Care when you define a problem, you try to find the causes, you prepare an intervention and you monitor it in interaction with the local community. Is COPC a way of blending on the one hand the ph view with the clinical view at the primary care level?
all the levels and what we really want to emphasize in this is from local to global one needs to think about and recognize this 4D model. Importantly, you have to think about all these different areas in education and not focus only on the first D which is often where physicians begins and stop. Nowadays when it comes to health systems we see that more and more health care is organized vertically, first for the communicable diseases like malaria, HIV, TB and now for the so called Non Communicable Diseases (NCD’s) not only in western countries but also in developing countries. Is that not a challenge for fragmentation? Because you were signalizing fragmentation as one of the risks? I think it’s a huge challenge and I think we have to look at ways in which we can avoid unnecessary fragmentation. A good example of that: if we developed a solid vital registration system that had good cause of death date for all deaths, we wouldn’t need disease specific registries like cancer registries, HIV, etc. and so I think we have to look at where the flagrant distortions are and more importantly where the great efficiencies are. We get more reliable data, more cheaply and more sustainably by building the foundations of the system. Having said that, we have to continue to work with national programs because they do help to mobilize resources and I think understanding how we manage that intersection is critical for those of us interested in keeping the populations or communities health in perspective.
It is and I think that’s an important area where the 4 D’s are in practice and operational and functional from a pedagogic perspective. However it doesn’t cover You emphasized equity and we are all 12
concerned about that. Often we see when vertical programs are organized that inequity by disease is created (eg food or educational grants only for HIV patients) Inequity by disease will challenge us and the health system itself will become a determinant of health but a negative one in terms of creating inequity. What do you think about that? I think more often than not the health system is associated with developing disparities or being associated with trend in greater disparities. I think where we have to look and understand much more fundamentally is how we build and implement progressive health systems in which they’re reducing inequity much more systematically. That takes a lot of work it’s simply moralizing and saying “let’s do something for the poor”. It means understanding all those diversion forces which take us in a direction where nobody on the outside wants to really go. So where are the areas, why are we getting side tracked, why are we getting fragmented, why are the barriers so high and how do we address these barriers in the system. So universal approaches are more important than risky selective approaches? I think an approach to the whole health system which is associated with our expectations for performance which is universal and based on the right to health and equity is indispensable. Dr Timothy Evans, Dean, James P. Grant School of Public Health at BRAC University and International Centre for Diarrhoeal Disease Research, Bangladesh Email: evanst@bracu.ac.bd
Improving Health Great Stories from Great People Khalid Gaffer Mohamed: Scaling Up Capacity for Family Medicine in Sudan At the Primafamed-workshop (www.primafamed.ugent.be), there was an impressive presentation by Khalid Mohamed, the director of the Gezira Family Medicine Project (GFMP) and Assistant Professor at the Department of Family and Community Medicine, University of Gezira in Sudan. Our SecretaryGeneral, Jan De Maeseneer, interviewed him!
You went to Norway for your studies after your graduation as medical doctor in Sudan. Why did you do that? Indeed I graduated at the University of Khartoum in Sudan, and then like many other African doctors, I travelled to Europe for economic reasons and to get a medical specialty; I travelled to Norway where I discovered the specialty of family medicine which was not known in my home country; I discovered it and really loved it. That took me 8 years- including the language and internship, and after the training, I returned to Sudan, where I am now working in training of family physicians.
the community. What you see is that this approach motivates students and increases their commitment to serve the needs of the population. So, at the examination, we asked them to report on the change processes they were involved in the communities. They reported on how they participated in the development of the health centers especially in communities where there is not yet a family medicine training place. Another characteristic is the use of modern information and telecommunication technology in the teaching and service provision. All the lectures are virtual-online, in addition to the telemedicine program where 2,160 online consultations took place in the first year.
“By developing family medicine and primary health care, we are able to really change the health systems in Africa.�
What are the main strategic lessons that we can learn from the experience in Sudan? I think the challenge is not only about money or economy, the challenge is about how we are able to convince the government, to convince academics, to convince our colleagues about the importance of family medicine and that we demonstrate the outcome of family medicine in a community. Your talk at the Primafamed-workshop, was very inspirational for the participants. Can you tell something about your motivation, about what drives you to put so much energy in this process? I feel accountable towards my community and towards my people and the people all over Africa and I think by developing family medicine and primary health care, we are able to really change the health systems in Africa.
Why did you focus your work in Sudan in scaling up capacity for family medicine? As you know, there is a huge need for family medicine practitioners in Sudan. We are actually 32 million people with just 10 family physicians in the whole country. So we needed a strategy to scale up family medicine. We started with 207 candidates who had finished their undergraduate training and who wanted to be trained in family medicine. We offered a 2-year program and now the government asks us to train 500 candidates in the next year, so that we can scale up capacity in family medicine in the whole of Sudan.
Thank you so much! Khalid Gaffer Mohamed, MD Family Medicine-Norway, Assistant professor, University of Gezira-Sudan Director of the Gezira Family Medicine Project Email: khaliddongola@hotmail.com
What are the main characteristics of the training program? Most importantly, the majority of the training takes place in
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International Health Professions Education Medical Education Training Program for Chinese Rural Practitioners Based on Low-Cost Health Care There are more than 640,000 rural clinics and 1 million rural village doctors in China and it is an essential part in national health care reform that such a large group can provide primary care with necessary professional training. Background: from barefoot doctor to village doctor There were 1.8 million “barefoot doctors” working in a rural area in China during the 1960s – 1970s. The name “barefoot doctor” is originally from the region near Shanghai. Some rural health workers needed to work in paddy fields as a part-time farm worker, so they were called this. They received preliminary medical training at the township health centers for about one to three months. Each of them could serve 2 to 5 small villages supported by the collective economy in villages. Since the 1980’s, barefoot doctors have disappeared and made place for “village doctors” who have private practices in villages supported by patients. Their education is still very poor; they received just 3 years of medical training after middle school. They now serve half of the rural population and have ±1.8 billion visits per year. Of course, the quality of their care is pretty poor with lots of malpractice. Low Cost healthcare – Haiyun (Sea & Cloud) Project, CAS since 2006 The Chinese Society of General Practice (CSGP), the Chinese Medical Association,
and the Chinese Academy of Sciences (CAS) initiated a program to train rural doctors over the whole country since 2011. The Low-Cost Healthcare Project (LCHP) aims to use appropriate high technology to deal with the common problems in most of the population, to prevent and monitor diseases in rural areas for reducing the whole cost of healthcare all over the country. The project has been initiated and implemented by SIAT-Shenzhen Institute of Advanced Technology, CAS. The project provides the rural clinics with medical equipment, a so called “Sea Terminal” which is an internet enabled medical device which can be used as a medical information workstation and screening device for primary care doctors. It can help doctors perform basic medical diagnosis. For example, multifunctional diagnosis table is a key product which innovatively integrates conventional screening functions into one table, including body ECG, BP, oxygen saturation, and Urine & Blood routine exams which can increase the accuracy of treatment at rural clinics and improve the capabilities of primary care workers. Along with the sea terminals, the low cost healthcare project also set up “healthcare Cloud platform” on which all the information stored in different medical information systems deployed over different hospitals can be integrated and interchanged through a cloud-computing platform.
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The platform can share medical resources among different hospitals and clinics of different scale. For example, a doctor who worked in a rural clinic can obtain collaborative help from a professional medical expert who works in a large hospital connecting with this platform. Online medical behavior monitoring & data mining can be implemented to help improve the management of medical services in rural areas. Joint-Training Program for rural-village doctors The low cost healthcare project also serves as a platform for GP training, which enables the sustainable development of the training process. Chinese Academy of Sciences (i.e. CAS), together with the Chinese Society of General Practice and the Chinese Medical Association has proposed a series of programs to train rural doctors. In the program, the training project of rural doctors is categorized into different levels and different groups. The project aims to train at least half a million rural doctors in 4-5 years (2012-2015) based on the implementation of low cost healthcare project. Yalei BI, Professor, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, P.R.China Email: Yl.bi@siat.ac.cn Yuan GU, Professor, Chinese Society of General Practice Email: Guyuan49@126.com
International Health Professions Education Medical Education The Beyond Borders Initiative
The Power of Yarning in Cross Cultural Learning and Student Engagement among Aboriginal, Torres Strait Islander and International Public Health Students Beyond borders- Aboriginal, Torres Strait Islander and International Public Health students: engaging partners in cross cultural learning Over the years, Graduate Diploma in Indigenous Health Promotion (GDIHP) and Masters of International Public Health (MIPH) students have expressed a consistent desire to engage with each other through student tutorials or any small group activity. MIPH students have expressed an interest in learning about Aboriginal and Torres Strait Islander (A&TSI) people and their health issues, recognizing contextual similarities in health priorities and socialcultural determinants. A&TSI students were often curious about the innovative solutions implemented in developing countries.
in our student population and thus, have responded to the University’s Strategic Plan to promote and enhance pathways for supporting A&TSI students. This innovation provides an opportunity for both groups to learn more about each other as they develop into globally competitive public health practitioners.
A&TSI students enrolled in the GDIHP have traditionally had very little contact with other students, as they come to the University in block schedules for a week or two then return to their respective A&TSI communities all over the country. All GDIHP students are A&TSI health workers. They are all A&TSI and are enrolled in one of two postgraduate A&TSI health programs at the School of Public Health. The GDIHP program has the largest percentage of A&TSI students in the School of Public Health, in the Sydney Medical School and, more broadly, the largest single A&TSI student cohort across the University. The program enrolls around 20 students per year.
Testing the waters In Semester 1, May 2012, A&TSI and MIPH students were grouped together and participated in student led tutorials in a unit called MIPH 5132 Disease Priorities and Social Methods, a core unit offered in the MIPH program. These 2 hour tutorials involved “Getting to know you” activities and a discussion of a topical disease/health priority within the context of A&TSI and developing country populations. These integrated tutorials became the first step in a series of proposed learning strategies increasing engagement between these postgraduate students and between two postgraduate Public Health programs.
“Has anyone seen the framed beautiful picture on the wall along the School’s corridor by the lifts? The photo shows tall and lean tribal African men walking in a line trailing each other. Those are my people. I belong to a warrior tribe- I am Massai.” MIPH student from Kenya
The tutorials brought out the creativity of the MIPH student facilitators as they used the Yarning or story telling tool, well known and integral to A&TSI communication, which the GDIHP students appreciated very much. Each student told their stories about how they came to Sydney University to study. Each tutorial group used huge world maps and A&TSI maps. All students were very impressed with the maps and the creative manner by which they each told stories using cut out cardboard airplane figures, strings, stars and other little devices to joyfully narrate their journey to Australia. Local MIPH students were also able to share their stories and were very appreciative of this rare opportunity to interact with their A&TSI student colleagues. The atmosphere was very informal, collegial, animated and warm. Discussion of the assigned topic and reading opened avenues to identify other major public health issues relevant to the communities represented by the stu-
MIPH students have diverse backgrounds (medical/public health related, science, social sciences, business, engineering, graphic design, law, media, education) with nearly half of the student cohort coming from overseas. Most of the international students come from low to middle income countries across the globe. The MIPH program has the largest percentage of international students in the School of Public Health. Through this Beyond Borders teaching and learning initiative, the MIPH and GDIHP programs demonstrate how we value diversity
“My country’s population has decreased significantly due to the ravages of years of civil war. Mine is a story of sadness and hope. Take advantage of this huge opportunity to study at Sydney School of Public Health because our future will definitely be brighter. I know that when I go home I will be able to help my people. I can make their lives better.” MIPH student from Liberia
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dents. Everyone shared and listened as A&TSI colleagues told Yarns, enriched with personal family anecdotes and clearly linked to their work experiences. This shared learning activity, though modest in scope, was a resounding success and has shown that our students want more of these cross cultural and cross program interactions. The learning exchange allowed students to learn about public health solutions used by others that may be adaptable in their communities. This success has inspired us to explore more innovative engagements between our programs, encouraging inter-professional and cross cultural learning within and beyond our classrooms. By integrating community-engagement learning and teaching strategies in our programs, we hope to foster and strengthen student and staff engagement while developing cultural proficiency, critical thinking, leadership, and mentoring skills. This is a Yarn of breaking down barriers, going down that road less travelled. Unbeknownst to us we may have created teaching and learning history in Sydney Medical School. A world of postgraduate interdisciplinary cross cultural public health teaching has only just begun. Like a little seed, Beyond Borders is germinating and is rich with potential. In good time, if nurtured with vision, courage, insight, indefatigable motivation, dedicated action from committed partners, creativity and wisdom, this Yarn about a small teaching innovation will grow and blossom, inspiring generations of similar Yarns yet to come. The Beyond Borders initiative in cross cultural learning is an affirmative response to the global call for transformative education in health professions education. Michelle Dickson, Giselle Manalo, and Suzanne Plater, Sydney School of Public Health/ Sydney Medical School University of Sydney Email: gmanalo@bigpond.com
International Health Professions Education Medical Education Barriers and Facilitators for Canadian Aboriginal Students in Medical School Access support this project. Enrollment of Aboriginal students in Ontario medical schools increased from six students in 2005 to more than 20 per year by 2010, suggesting that some effective strategies have been identified. In Canada, Aboriginal people have experienced a history of colonization, cultural and social assimilation through the residential schools program and other policies, leading to historical trauma and the loss of cultural cohesion. The resultant power structure undermined, and continues to undermine, the role of Aboriginal people as partners with healthcare workers in their own care and treatment. Teresa Naseba Marsh
Today, there are approximately 3.3 million Aboriginal people living in Canada, of whom about 61% are First Nations, 34% are Metis, and 5% are Inuit. These represent three separate groups, all with unique local geographic and linguistic heritages, cultural practices, and spiritual beliefs. Currently Canada needs almost 2,000 Aboriginal doctors to care for the health of Aboriginal people, today there are roughly 200. Half of the Aboriginal people of Canada live in rural areas, therefore, rural shortages of healthcare services have a particular impact on the Aboriginal communities. Healthcare obstacles include infant mortality, diabetes, obesity, renal failure, respiratory problems, and heart disease—all of which have higher rates of prevalence among Aboriginal Peoples. Well-defined cultural safety benefits stem from having Aboriginal doctors deliver health services to Aboriginal people, such as an understanding of traditional medicine, diet, and social constraints. In 2004, the Association of Faculties of Medicine in Canada (AFMC), as part of a social accountability agenda, committed to improving the health of Canada’s Aboriginal people by increasing access to medical schools for Aboriginal applicants, as well as educating all Canadian medical students about Aboriginal health issues. All Canadian medical schools agreed to
Currently Canada needs almost 2,000 Aboriginal doctors to care for the health of Aboriginal people, today there are roughly 200. Canadian medical schools have responded to the need for Aboriginal doctors through a variety of initiatives with varying success. In many regards, the push to increase the number of Aboriginal physicians is also part of a concerted effort by government, schools, the AFMC, and the Indigenous Physicians Association of Canada (IPAC) to increase physician human resources throughout Canada. Within this strategy, Aboriginal needs are most often identified with rural and northern initiatives. Rourke (2006) described the overall strategy as part of social accountability/ responsibility, wherein medical schools can make the greatest contribution to the health and well-being of humanity. In light of the difficulties that exist in the current health status of Aboriginal peoples as well as the lack of medical schools attracting Aboriginal candidates, the purpose of this qualitative study using participatory action research (PAR) is to iden16
tify the factors that hinder and facilitate Aboriginal students’ access and admission into medical schools in Northern Ontario. Participants will be invited to participate in a four-phase study process that will entail the building of relationships with community members on the Atikameksheng Anishnawbek (Whitefish Lake) reserve. Semi-structured interviews and focus groups will be utilized to collect information. Sample Size (n)= 30, which includes: Parents of Aboriginal Students, Elders, Chiefs and Council members and other key leaders in the community, Aboriginal medical students at Northern Ontario School of Medicine, and Aboriginal doctors. Upon completion of the study, a series of strategies will be suggested to enhance and improve access and admission of Aboriginal students to medical schools in Northern Ontario, including strong working partnerships with local/regional schools, colleges, the Aboriginal health workforce and other university disciplines to ensure that potential Aboriginal medical students are identified, regular recruitment activities at local schools/ communities, health services and other educational institutions; medical students and graduates to act as role models and participate in mentoring programs; university orientation opportunities, summer camps, bridging and premedical programs that are targeted at a range of age groups and educational levels. Further this research may encourage Canadian medical schools and principal stakeholders to ‘adopt strategies to initiate and coordinate partnerships that would open pathways to medicine from early childhood through to specialty practice’ as well as recruitment strategies that would provide support to potential Aboriginal medical students at different life stages including primary and secondary school and mature age. Teresa Naseba Marsh; MA, RN, RCC; Psychotherapist, Healer, Consultant, Motivational Speaker Email: thunzi@me.com
International Health Professions Education New Institutions and Programs Rural Medical Scholars Program (RMSP) No stoplights (well maybe a couple), clean air, wildlife, hunting and fishing, cycling, swimming, skiing and boarding, hiking, beautiful visas, and traffic jams of two cars at a stop sign. This is a life style rural communities want to share. And for our students one sought after for training and hopefully future practice.
to allow preceptors and students to craft the best experience possible for the RMSP week. The new curriculum allows welcome respites from the grind of basic sciences at regular intervals over the two years. As medical professionals in training the students meet with their preceptors on the first visit and meet hospital and community leadership. This is accomplished by signature lists, shared workups in the hospital with Interprofessional staff, community visits, meeting elderly, etc. Each student will utilize these experiences to write a community health assessment and plan a project.
The mission of the University of Minnesota Medical SchoolDuluth Campus is to be a leader in educating physicians dedicated to family medicine who serve the health care needs of rural Minnesota and American Indian communities, and to discover and disseminate knowledge through research.
At the end of year one they present their communities to their learning communities and debrief the first year. In year two they complete their projects.
The University of Minnesota Medical School Duluth has revised its curriculum. The revision embraced the mission of the University of Minnesota Duluth Regional Campus. The revision re-emphasizes and allowed expansion of rural sites. We were able to enhance our traditional distributive preceptorship with health system and community involvement. This program is longitudinal and occurs in five weekly periods over two years. The expanded time enhances student and community bonding.
We created the reflection rubric for use this year and going forward. Many have never reflected, a skill needed for reflective practice. The use of the rubric is a work in progress. We also struggle with housing. Not readily available in all communities and not all physicians are willing to provide housing for students. The students also feel they are imposing. We are working with communities. It is to the community benefit to find a mechanism to provide housing for professional students of all professions and disciplines; it can only benefit them in the long run. We have considered empty nursing home beds. The hospitals seldom have empty beds. The hospitality industry in rural areas are not willing to provide discounted rooms, etc.
We carefully select our classes in Duluth and with expanded distributive rural and Interprofessional training we seek to increase the probability our students will further our mission of service to rural MN. Before traveling to their communities they are instructed in performance of patient history and physical exams. We update their CPR/BLS/AED cards, teach them to suture, scrub for surgery, and other important basic skills.
It is exciting to observe the effect of supportive and willing preceptors, hospitals and health systems, and especially community on students. These wonderful foundational healthcare experiences engender respect and desire for rural practice and the joy of rural living.
RMSP is an exciting time with focus on preceptorships with rural family physicians, participation in Interprofessional care in our rural health systems, and community involvement. We emphasize patient care and utilization of new clinical skills, oral presentations to preceptors and up loading History & Physical examination and SOAP (subjective, objective, assessment and plan) assignments to BlackBag (Med School web-based curriculum support system). Clinical Faculty Advisors grade the submissions with the use of our grading rubric. We also ask them to focus on the seven medical school competencies as well as becoming familiar with our rural competencies. Reflections are assigned to RMSP and are also up-loaded to be assessed by clinical and/or basic science faculty with our grading rubric for reflection. We have six learning communities with a basic and clinical faculty assigned to each. We follow our cohort for four years as advisors and mentors.
Raymond Christensen, MD, Associate Dean for Rural Health, Universtity of Minnesota Medical School, Duluth campus. Email: rchriste@d.umn.edu
We write a learning contract for the students to share with their preceptors. We update their basic science and clinical learning
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International Health Professions Education New Institutions and Programs Selecting Medical Students to Help Address Rural-Urban Physician Maldistribution in Nepal The newly established Patan Academy of Health Sciences (PAHS) in Nepal has moved away from the current convention of selecting students solely based on past scholastic achievements that favors candidates from urban and well off families. PAHS student selection strategy heavily favors candidates from rural and disadvantaged groups, which is known to likely improve retention of health workers in rural remote areas in the future and, thereby, help improve health service coverage there. It consists of (1) Personal Qualities Assessment (PQA), (2) Multiple Mini-Interviews (MMI) and what PAHS refers to as the (3) Social Inclusion Matrix (SIM) for selecting students having the necessary cognitive ability and personal traits/attributes usually not assessed by the past scholastic achievement and/or the memory driven test scores of candidates.
from PQA and MMI form the final selection grid for all scholarship seeking candidates. Only the scores of PQA and MMI are used for selecting self paying students. Scholarship: PAHS provides partial or full scholarship to nearly 60% of students so as to enable students from socio-economically disadvantaged sections access medical education. The final certificate is withheld until candidates complete 2-4 years (partial vs full) of mandatory rural service after the training. Since 2010, PAHS has enrolled two batches of 60 medical students of which nearly 60% are from rural areas, about 50% are female, and nearly 40% are from a socially disadvantaged group. 26.5% of the students were selected from the 9 remotest districts of the country in 2011 compared to 5.6% in 2010. All the scholarship students received bonus points on HDI based on the region of their permanent residence. There has been a steady increase in the enrollment of students from rural origin in both the scholarship (76.5%) and non–scholarship (46.5%) groups, which is considered to be very important in enhancing deployment of physicians in rural/remote areas in the future. The preliminary student selection data shows that the new selection strategy employed by PAHS seems to ensure a good representation of students from geographically remote, underserved and rural areas, female and ethnic/disadvantaged groups.
Administered as the written test in collaboration with the University of Newcastle, Australia, PQA forms the 1st step of the selection process. The psychometric tool, validated locally before adoption, is comprised of four subsets of tests namely, Mental Agility Test (MAT); Moral Orientation in Justice and Caring (MOJAC); Narcissism, Aloofness, Confidence and Empathy (NACE) and Personal Characteristics Inventory (PCI). These tests assess candidates’ cognitive and non-cognitive qualities and attitudinal traits such as general mental ability, critical thinking, problem solving, communication skills, empathy, psychological robustness, and integrity commonly believed to be essential for the study and practice of medicine.
The new selection process has been synchronized with the multi-pronged innovative strategies in the areas of curriculum design, teaching methodologies, training sites, student assessment, and faculty development. A network of partnerships has been built with the community of innovative medical educators and institutions across the globe to learn from their best practices and develop institutional/faculty capacity. Partnership with the national health system and local communities is being developed for creating synergy for the appropriate deployment and sustained retentions of graduates in the rural area in the future.
MMI forms the 2nd step of the selection process. Objectively structured scoring checklists are used in multiple interview stations to draw indirect inferences on candidate’s various skills and qualities such as communication skills; critical appraisal skills; decision making skills; organizational skills; and sensitivity, compassion and empathy, which could not be assessed through the written tests. The SIM is the 3rd but most critical steps of the entire selection process. The SIM provides preferential scores to the applicants based on their socio-economic characteristics. They include caste/ethnicity, gender, remoteness/rurality, and the Human Development Index (HDI), applicants’ permanent residence, the types of school candidate studied grade 8th, 9th and 10th (public vs private), and candidate’s past work experience as paramedics in rural areas. The preferential bonus scores thus obtained plus the scores obtained
However, it is premature to make any definite conclusion from the limited available data. Lack of comparison of this data with national and international studies is another limitation of this paper. Shambhu K. Upadhyay, MB, MPH, Associate Professor of Public Health, Patan Academy of Health Sciences (PAHS), Nepal Email: shambhu.upadhyay@pahs.edu.np 18
International Health Professions Education Problem-based Learning and Community-based Education Teaching Final Year Medical Students in the Community Keele University School of Medicine, UK, was established in 2002 and was initially affiliated with and delivered the Manchester School of Medicine’s curriculum. The development of our own ‘Keele curriculum’, which was implemented from 2007, was an opportunity for innovation and creativity, which included increasing the amount of time students spend in primary care settings. The vast majority of patient care is in the community. Also, especially in the United Kingdom, hospital services are changing rapidly, with patients spending less time in hospital and general practitioners becoming more involved in complex care. There are other compelling reasons why students should learn in community settings such as to learn to manage people who have multiple chronic diseases and complex medication regimes, to appreciate the benefits and challenges of providing continuity of care throughout people’s lives, and to gain an understanding of social determinants of health by seeing patients within their communities. At Keele, each student spends 113 days in general practice. This represents 25% of clinical curricular time and, in the final year, 15 weeks are spent in general practice. This placement is a clinical assistantship designed to prepare students for professional practice. They take the lead role in a minimum of 375 consultations with the support of their GP tutors. They have serial workplace based assessments, and are given very specific feedback tailored to their needs. This feedback is informed by direct observation of their practice and helps them to focus the development of their consultation and procedural skills. During the assistantship students perform a patient satisfaction survey and participate in a multisource feedback exercise and they are encouraged to reflect upon the outcomes to identify constructive learning points. These activities have an intrinsic
educational value and are an excellent preparation for their postgraduate careers when they will be integral to their continuing professional development. They also perform an audit related to the work of the practice and often in the field of chronic disease care. With their GP tutors they identify a topic which is of value and interest to themselves and the practice. This thread of being useful to the practice runs through the placement and those who make the most of their time in the practices are invariably missed by the patients and the staff when they leave. Working alone in a practice, which may be remote or rural, may lead to a sense of isolation for students. For this reason, they spend a half day per week learning in ‘clusters’ where three or four students from neighbouring practices meet to learn together with the support of one of the GPs. These sessions are directed by the students, and include peer teaching about mutually agreed topics which helps develop their teaching skills, which are important for all doctors. There are also several ‘away days’ where students work in larger groups on topics such as safe prescribing, death certification and end of life care. In order to develop a connection with the communities in which they learn and to promote socially responsible practice, students spend a half day per week working on community projects, for example, collaborating with a local school to deliver sex education to teenagers. These projects may last longer than one group’s placement and thus they learn the skills needed to hand their projects on to subsequent groups. These projects extend the students’ communication, negotiation and leadership skills. Our final year placement is aligned with the principles of a longitudinal integrated clerkship. Our students participate in all aspects of patient-centred care over a period of time, and have on-going learning relationships with clinicians who provide care over all medical disciplines. Students observe the progress of a range of illnesses over time and through the stages of a patient’s life. We are not aiming to train students to be general practitioners but to educate them to be excellent clinicians with a deeper understanding of primary care in whatever future medical discipline they choose. Placed in the communities in which patients live and receive most of their medical care and enabled to consult with large numbers of patients with the support of doctors with whom they have sustained relationships, our students have a golden opportunity to achieve excellence. Dr Maggie Bartlett, Clinical Lecturer in Medical Education, Keele University School of Medicine, UK Email: m.h.bartlett@keele.ac.uk
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International Health Professions Education Problem-based Learning and Community-based Education Go Global Program, Perth “Go Global” is an exciting program happening out of Curtin University in Perth, Western Australia. It adopts an innovative and valuable approach to training healthcare professionals, while at the same time, builds capacity of communities overseas. When you think of studying a university degree, many think of spending time in lecture theatres, writing essays and completing exams. In the past, many held the belief that the best learning took place in the classroom and was the result of good teachers, text books and an intrinsic motivation to learn. However, these days more and more universities are expanding the horizon of what constitutes an education – for example the increasing move towards virtual and online learning. But when it comes to training health professionals, more practical, realistic and functional modes of teaching and learning are being explored. Curtin University’s, Faculty of Health Sciences, Go Global program is an innovative program that is changing the way health professionals are trained in Western Australia. This program embeds inter-professional practice within a service learning model, which sets it aside from the majority of other clinical fieldwork experiences for health professionals. Go Global embodies work-integrated-learning in an international setting with the aim to provide students with a global perspective of healthcare delivery – and provide a service to the community at the same time. Go Global started humbly by sending six occupational therapy students to China in 2000. Over time the program has grown from strength to strength with the Faculty sending more than a 100 students from eight different professions to five different international host sites across the world in 2012. The program offers cross cultural interprofessional clinical opportunities for final year students from various disciplines
across the Faculty of Health Sciences. These include speech pathology, occupational therapy, physiotherapy, nursing, pharmacy, dietetics, health promotion and international health students. With the program, the students visit international partner sites in Ukraine, India, Cambodia, China and the Philippines. Go Global takes students out of the lecture theatre and propels them into communities facing “real-world” problems in the developing parts of the world. The placements are interprofessional in nature. They involve students working collaboratively across disciplines to plan, deliver and evaluate sustainable community healthcare services. At the same time, the projects also meet the placement criteria for their specific disciplines and the learning objectives for their individual courses. Go Global is also innovative in that it adopts a ‘service learning’ model, allowing meaningful connections to be made with international ‘host’ communities. Go Global integrates the involvement of community partners in the planning and coordination of the placement. And by adopting this approach, the program balances service (clinical intervention) and learning objectives, addresses community concerns, and emphasises reciprocal learning and the community partner as co-educator. In this way, it is possible to determine the specific needs of the host community and devise a suitable service or intervention to meet that need. The program’s aim is therefore not to burden the local community, but to support them and educate them and build their capacity, while simultaneously, providing our students with a valuable learning experience. During the trip, Go Global students are required to keep “reflective journals” in which they record personal progress, changes in their mindset and learning ex20
periences. A reoccurring theme has been that these placements create an opportunity for students to develop global perspective, cultural competency and apply knowledge in a service-learning context. An occupational therapy graduate reflected (about Go Global), “This was an incredible experience and opportunity that gave me much needed insight into the lives and challenges of individuals in a different country. It has also increased my understanding of the roles of different professions and how we can work together and enhanced my personal and professional confidence.” A speech pathology graduate reflected, “Go Global was the most incredible learning experience. I can safely say that the experience gave me skills - not only of humility and perspective - but professionalism, working in a team, working with another culture despite the language barrier, and working in a resource-poor environment having to use my imagination and creativity to develop tools and equipment I would usually have access to here in Australia.” In 2010 Go Global won a national award from the Australian Learning and Teaching Council for Programs that Enhance Learning: Innovation in Curricular, Learning and Teaching. The program continues to operate and is continually looking for new and innovative ways to build capacity in developing communities, while producing culturally competent and socially accountable graduate health professionals. For more information about the program, please visit http://healthsciences.curtin. edu.au/go_global.cfm or contact us at goglobal@curtin.edu.au Kristy Tomlinson, Go Global Supervisor, Interprofessional Student Coordinato,Faculty of Health Sciences, Curtin University Email: Kristy.Tomlinson@curtin.edu.au
International Health Professions Education Distance Learning Using Information Technology in Health Professional Education to Improve Global Health Outcomes The Importance of Increasing Teaching Capacity in Medical Education Global health workforce shortages are complex. To begin to address these shortages, we must increase the capacity of health education systems around the world. In 2006, the World Health Organization (WHO) identified a global deficit of 4.3 million health workers and the need to use information technologies (IT) for a solution. Fifty-seven countries faced severe shortage of health personnel, unable to deliver essential, basic health interventions. Current health education models are not meeting population needs locally or globally. Developed nations source a significant portion of their health workforce from overseas, failing to achieve adequate numbers without importing talent. The WHO Global Code of Practice on the International Recruitment of Health Personnel, published in 2011, mandated that each country meet their national health personnel requirements sustainably, through education and retention, using their own human resources for health. Australia, Canada and the United States all benefit from the services of foreign trained doctors, who comprise approximately one quarter of the medical workforce. Participating as a recipient in the ‘Brain Drain’ phenomenon remains a politically acceptable and prominent health workforce management strategy. One of the greatest limitations to improving health outcomes globally is a nationalist approach to health systems, without regard for global health needs.
“The ‘Brain Drain’ phenomenon remains a politically acceptable and prominent health workforce management strategy.” Cost of Medical Education Medical education as it is currently delivered is too expensive. Information technology should be used to lower the cost of health professional education, making it more palatable for countries to train their own workforce. Emphasis on the affordability of health professional education would also facilitate interdependent capacity building between health education institutions, ideally overcoming the contextual limitations of high and low income settings. The pedagogy of health professional education must evolve to prioritize service over tradition and define success in
terms of global population health outcomes. Information Technology in Health Professional Education Feelings of apprehension associated with the idea of IT reforms and ‘going online’ with health professional education held by those entrenched in the a culture of tradition (particularly in medicine) must be addressed in order to maximize the potential for IT to improve health education outcomes. NextGenU. org is an online Health Science university, founded in 2001 and fully launched in 2012: it has the potential to democratize education. NextGenU.org delivers comprehensive, highquality online education, free from financial and geographic barriers. It is one answer to the global workforce shortage and a shining example of what IT can offer the medical pedagogy. Online education does not and should not subvert the high standards of a regulated, accredited, competency-driven, hands-on education with appropriate supervision and assessment. Partnered with leading universities, professional societies and government organizations (including Grand Challenges Canada, the US CDC, World Bank and WHO), NextGenU.org is a leader in the provision of free, online, accredited, higher education. NextGenU.org courses are based on published competency-based curricula and provide online knowledge transfer combined with skills-based local mentorships and a global online peer community. Information technology offers the best medium to deliver significant elements of traditional medical education. Greater interdependence and sharing of resources between educational institutions would expose learners to high-quality educational materials suitable for a wide array of learning styles. Face-to-face learning, practical mentorship and hands-on experience cannot be replaced by IT. IT could and should be used to relieve educators of time-intensive repetitive lecturing, enabling them to focus their energy on high yield learning interactions with their students such as mentorship and clinical supervision. Using IT to support a distributed learning model increases program capacity, reduces pressure to relocate for further education and exposes learners to diversified and unique clinical experiences. eLearning facilitates the use of satellite training sites, allowing programs to expand their numbers by placing students more remotely for practical experience 21
without compromising continuity in education. Flinders University School of Medicine, based in Adelaide, South Australia, provides one example of a distributed learning model, operating the Parallel Rural Community Curriculum and the Northern Territory Medical Program. Flinders benefits from placing students rurally because they can accommodate greater numbers of students and offer more varied clinical exposure in addition to more conventional local hospital based learning. Flexible access to online materials enables students to move through different topics at a pace that suits them and reflects their individual clinical experiences. Longitudinal Integrated Clerkships, such as the Harvard-Cambridge model, provide an excellent example of student-centered learning. Students are assigned a panel of patients to follow over the course of the year, gaining exposure to core clinical subjects through their patients’ interactions with various specialties. In contrast to sequential immersion in a particular discipline for a discrete period, students who experience continuity in patient care enjoy greater satisfaction with the ‘atmosphere for learning’ and enjoy a contributory role, escaping the erosion of student morale common to clinical study years. Finally, the ease of online evaluation and assessment facilitates more rigorous, regular measurement of learner progress, enabling individualized learning and continuous improvement of programs. Areas of weakness can be identified early and addressed with additional support. The generation of adult learning data consolidated across institutions could be of great value informing ongoing health education improvement. Conclusion Policy-makers should act on WHO recommendation regarding the dire shortage of health professionals and the need to use IT for a remedy. Countries should train at least their own health professionals. The shortages in medical personnel will continue unless we unleash the power of IT. Greater utilization of IT will require changes in attitude and approach on the part of governments, health professional education providers and students, which are unlikely to happen without support from across the health profession. I urge you to add your support to this cause. Ainsley McCaskill BMBS BSc, NextGenU.org Email: amccaskill@nextgenu.org
International Health Professions Education Interprofessional Education How to Prepare Future Healthcare Professionals for Interprofessional Collaborative Person-Centered Practice The mounting health/social needs of populations along with the global shortage of human and financial resources, have forced policy-makers to call for revising the way of health care is currently provided and subsequently, the way health/social professional students are educated (World Health Organization, 2010). In Canada, the Canadian federal government through the Health Canada IECPCP program (2006) and in US, the Lancet commission report (2010) are fostering a change in the delivery of care within their respective health systems. In support of Interprofessional Collaborative Person-Centered Practice (IPCPCP), these governments are demanding a transformative change in professional education towards interprofessional educational socialization (IES). By projecting the idea of equality in healthcare, IES is widely recognized as a key measure for enhancing and reforming healthcare practice towards IPCPCP. However, many professionals view IES as a potential threat to their professional identity and try to protect their own sense of professionalism, which in turn inhibits their capability to learn/work with other health/social professions. These ‘turf protection’ behaviours are evidenced to be deeply rooted in the way providers are socialized in their professional education. The current profession-specific socialization/education isolates students from learning/working with students from other professions, causing the development of solely uniprofessional identities. This results in a lack of understanding and exposure to other disciplines, which contributes to persistent ignorance and misunderstanding about other disciplinary colleagues’ roles and contributions in practice. Change within health/social care educational programs is required to facilitate a shift in students’ socialization process toward the development of strategies for cross-disciplinary learning that can promote the development of both professional and interprofessional identity (referred to as dual identity) and a subsequent IPCPCP. There is growing recognition of IES
in the literature; gaps remain leaving little guidance as how to facilitate the implementation of IES. Seeking to fill the gap, my PhD dissertation study examined whether my three-stage IES framework could offer a means of facilitating the development of interprofessional socialization and duel identity. My findings substantiated that this IES framework provides a practical guideline for transforming uniprofessional identity to dual identity through a threestage process: 1) breaking down barriers; 2) interprofessional role learning; and 3) dual identity development. During the first stage, students are provided with an open and trusting environment wherein they are encouraged to critically challenge and reflect on their own/ each others’ perspectives in order to improve collaborative practice. By doing so,
The current professionspecific socialization/education isolates students from learning/working with students from other professions, causing the development of solely uniprofessional identities participants gain awareness about their confined uniprofessional perspectives, the stereotypes they hold toward other health professionals, and how these views impact collaboration. This awareness leads students to experience a transformative process in their perspectives, gaining new insight about their own and other professionals, leading to value interprofessional practice in action. By the end of the first stage, students embrace enhanced clarity about their own roles, knowledge and skills, and gain new understandings of other professions thereby increasing their readiness for interprofessional role learning. In the second stage of IES, students are 22
required to work together using simulated case studies within interprofessional learner groups (IPLG). This stage allows students to demonstrate CIHC interprofessional competencies, which include: • role clarification/role valuing, • patient- centeredness, • team functioning including team commitment, • interprofessional communication and listening, • collaborative leadership, and • interprofessional conflict resolution. During the third and final stage of IES, continuing with learning and practicing the competencies through the use of simulated case studies and/or professional practice help IPLGs to build an unified collaborative team, in which the complementarity of the roles and perspectives of team members in developing holistic patient care plans are valued, leading to the development and the internalization of dual identity. This dual identity development assists students to further correct their previous held disciplinary prejudices, and to feel empowered in viewing (and seeking future) IPCPCP through both their own professional lens and as a member of an interprofessional community. Conclusion As a mid-range theory, the IES framework provides the means to improve our understanding of students IES and the process/ strategies to form/develop dual identity to promote an affinity towards interprofessional collaborative teamwork. This understanding allows us to better inform IPE/ IPCPCP curriculum development, and the policy needed to implement such learning and practice opportunities.
Hossein Khalili, RN, BScN, MScN, PhD (c), Professor, School of Nursing, Fanshawe College, London, ON, Canada, Email: hkhalili@ fanshawec.ca
International Health Professions Education Leadership Column Roger Strasser In September 2002, Dr. Roger Strasser was selected as the Founding Dean to create the newest medical school in Canada in over 30 years—the Northern Ontario School of Medicine (NOSM) in Ontario. Prior to his appointment with NOSM in 2002, Dr. Strasser was Professor of Rural Health for Monash University and Head of the Monash University School of Rural Health, in Australia. Between 1992 and 2004, Dr. Strasser also had an international role as Chair of the Working Party on Rural Practice of Wonca, the World Organization of Family Doctors. What change processes have you been part of in the past? I guess the biggest change I’ve been involved in, was starting a whole new medical school, the Northern Ontario School of Medicine (NOSM). I moved from Australia to Canada in 2002, and essentially really from scratch was involved in starting this new school.
a vision of what the future will look like. Create an excitement that the future will be better than where we are now. Changes are always difficult and often painful for people, if they have to give up what they have been used to doing and doing things in a different way. People have to believe that it’s actually worth the effort.
What would you define as the first step towards successful change? By the time I came here, the government had decided that there would be a NOSM and I guess the first prerequisites had been covered. So the school came into existence because of wide spread community movement that said if we were ever going to turn around the chronic shortage of doctors and other health care professionals in Northern Ontario, if we ever want to improve the health status of the people of Northern Ontario, we need to have our own stand-alone school of medicine. I was recruited to lead that. The first big challenge was to persuade people that there really would be a NOSM because it’s a common experience in rural areas of Northern Ontario, that the government makes an announcement and afterwards nothing happens, announces the same thing again, and nothing happens and eventually nothing happens.
Every change process has its successes and failures. Can you give us some examples? In recruiting people and bringing people on, it works for some people and doesn’t for others. I remember one individual that we recruited, who seemed to have all the right qualifications, and in the end he didn’t seem to connect with the other people and he didn’t seem to know how to get from here to there. And when I sat down with him and asked where he expected to be in 20 years time, he just named the city. His attraction to the school was that he wanted to go back to his home city.
So just because I moved from the other side of the world with my wife, who is an academic family physician and 5 children, didn’t mean that it was going to happen this time! It was about building people’s confidence!! Make people believe that it can and would happen. In this process, what kind of a leader would you say you are? How would you describe yourself as a leading person? As a leader, it’s about being able to focus people’s attention on the future and have
This is just one example, but recruiting the right people is a big challenge, and often doesn’t work out. We had to recruit fast and you can obviously only choose from the ones available. What role do you give to stakeholders like students, staff, community leaders,..? NOSM, came to existence as a result of a community movement and it’s built into the founding documents of the school, the social accountability mandate, the commitment to be responsive to the need of the people of Northern Ontario. That mandate really guides everything. It means we have a very strong focus on active community participation in all aspects of the school, what we call community engagement. It’s community both in terms of geographic local community and also special populations in Northern Ontario, like Aboriginals. So community is very much a part of the school.
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With regards to the faculty members and staff, I would say that it’s a continuing work in progress. In the early years we had short deadlines, so it was all hands to the pump. And now we are really working within the school to encourage and support more active staff and faculty participation into the development of the school and the sense of collective contribution to further guiding of the school’s development according to the core values of the school. So for example, we have several working groups in the school but one is the organizational effectiveness working group which has spent some time looking at how you take the values and operationalize them. That’s one of the ways in which the staff and faculty are involved. And the students, well the school really came to life when the first group of students started, we wouldn’t exist without them, there is a very strong student involvement, as you can see here in this conference! How do you make sure that your changes are and stay sustainable, even after you have left? That’s something we are working on very much now, and it’s about the culture. We do things here within the school and it’s been very pleasing that we’ve been in the last couple of years recruiting people who have been drawn to the school because they wanted to be part of it, of an institution that’s guided by social accountability because they want to make a difference in that kind of way. So what I want to do is to make sure that that inspires everybody, this focus on social accountability, and so it’s part of the way we do things. It’s the core of all decisions made and everything that we do, so for me is the key to sustainability of this school! Dr Roger Strasser, Dean, NOSM Email: roger.strasser@nosm.ca
The Like-Minded Working Together THEnet
Joining Forces for Greater Impact
THEnet Meeting, Ghent
During the first decade of the century scaling up the health workforce was finally recognized as a major bottleneck to reaching the Millennium Development Goals. Today, the momentum for achievement of universal health coverage – where everyone has equitable access to needed health services without risking financial hardship – is growing. Clearly universal health coverage can’t happen without equitable health systems including sufficient numbers of appropriately trained and motivated health professionals willing to work where they are most needed, particularly in underserved areas. According to the Lancet Commission on the Education of Health Professionals for the 21st Century, the predominant “ivory tower” business as usual model is no longer acceptable. Academic institutions must play a central role since they produce the health workforce and generate research needed to inform policy makers. Yet, few health professions schools—in high, middle or low income countries—hold themselves accountable for producing outcomes aligned with health workforce, priority health, and health system needs. However, in recent years there is growing international recognition that schools training health professionals should be held responsible for meeting the needs of the societies they serve. Several initiatives including The Global Consensus for Social Accountability of Medical Schools, which grew out of a The Network: TUFH Task Force, call for schools to improve their response to current and future health-related needs and challenges in society and reorient their activities accordingly (Global Consensus for Social Accountability of Medical Schools, 2011). The principles and practice of socially accountable health professions education are certainly not new. For decades several schools working with and in underserved communities, have been striving towards greater social accountability, i.e. defining their success through the lens of health equity and by how well they meet the needs of the populations they serve. Many of them are members of The Network: TUFH and a smaller and younger like-minded organization called the Training for Health Equity Network: THEnet. THEnet is composed of 11 schools committed to transforming health-professions education to improve health equity. Located in underserved and rural regions of Africa, Asia, Europe, the Ame-
ricas and Australia, they were brought together initially through a project at the Global Health Education Consortium that sought out innovators in addressing global health-workforce challenges. Realizing they shared common principles, approaches and goals, these previously isolated innovators, joined forces in December 2008. The aim was to collaborate to build evidence to support effective and credible change towards greater impact and accountability of academic institutions on health and equitable health systems development. THEnet schools agreed to “a core commitment to achieving equity in health care and health outcomes through quality health professional education, service and action-oriented research responsive to the needs of and embedded in, undeserved communities and health care systems.” The first priority for THEnet was to develop a comprehensive Evaluation Framework as a tool to measure schools’ progress towards social accountability and thereby their ability to increase impact on health outcomes and health systems they serve across institutions and contexts. THEnet used Boelen and Woollard’s Social Accountability Conceptualization – Production – Usability model (CPU model) as a foundation for evolving its framework: Evaluation Framework for Socially Accountable Health Professional Education (2011). The Framework assist schools and THEnet establish priority areas for research and improvement. Hence a core focus of THEnet’s activities is cross-institutional research. THEnet has already played a key role in the global dialogue on health workforce development and retention in disadvantaged regions. It was a key player in developing the Global Consensus on Social Accountability of Medical Schools (GCSA); sits on the Institute of Medicine, Board on Global Health Forum on Innovation in Health Professions Education; and contributed a background paper on THEnet’s lessons learned to the influential Lancet Commission on the Education of Health Professionals for the 21st Century. The challenge of equitable universal health coverage requires all hands on deck. THEnet realizes the important joining forces with like-minded organizations such as The Network. It is exploring close collaboration with The Network and others to share resources; conduct joint research, advocacy and tool development. The first step towards greater collaboration with The Network was agreeing to organize key THEnet meetings around The Network conferences to reduce our carbon footprint as well as create a regular platform for collaboration and mutual support. It is also hoping to collaborate on specific projects such as the development of a second version of its Evaluation Framework, which will be used by WHO to help schools implement its upcoming Transforming and Scaling-up Education and Training for Health Professionals: World Health Organization Guidelines for Health System Policy-Makers. Professor André-Jacques Neusy, Chief Executive Officer and Björg Pálsdóttir, Executive Director, Training for Health Equity Network, New York, USA and Baisy-Thy, Belgium Email: bjorg.palsdottir@gmail.com 24
Student’s Column Out of the SNO Pen Sawasdee! Sawasdee is the word we use to say hello in Thailand. Therefore the Thai students are very pleased to welcome you in Ayutthaya, the old capital city of Thailand. We are preparing an interesting student program and want to give you a little sneak preview! The student’s program will consists of four parts: 1. Medical students will discuss and exchange ideas on many topics about the public health system in each country while enjoying a cocktail party in the evening. 2. We will learn you about the cultural heritage of Thailand. You will be with us to celebrate Loy Krathong, an old annual festival in Thailand. The name could be translated “Floating Crown” or “Floating Decoration”, and comes from the tradition of making buoyant decorations which are then floated on a
river. This festival is traditionally performed on the full moon night of the twelfth lunar month. This is the time to pay our respects to the Goddess of Water. 3. Study tours will be organized to visit several health organizations such as - Wat Prabat Nampu temple: An AIDS patients and HIV positive orphans project - Thanyarak Institute Host of a Drug Dependence treatment program 4. Congratulation party to celebrate the medical students who graduated this year with Chinese dishes! Kotchakorn Jeeratunyasakul; Sareefah Chumraksa, Students, Princess of Naradhiwas University Email: jern_jernz@hotmail.com
Students’ Interview The Big Five Jan Baudonck, 21 years old from Ghent University, Belgium, is a master student in Public Health. He has already completed a bachelor degree in nutrition and dietetics and is one of the very motivated Belgian students who will join us at our Thailand Conference. 1. Why did you choose to study Public Health? Before I started my master studies in Public Health, I did a bachelor in nutrition and dietetics. The reason that I have chosen this study is because of my interest in healthy nutrition, human behavior and the functioning of the human body. During this 3 year educational program I recognized the important role of a good working health system to protect the community against diseases. Because I wanted to learn more about public health and how to develop and implement interventions to promote healthy lifestyles, it was natural to choose a master study in Public Health. I’m very eager to learn. 2. What is your opinion about innovative educational formats like problem-based learning (or the education format that your own Faculty uses)?
Problem-based learning is something that we don’t see enough in our education. Nevertheless, I find this a very important format. It helps me understand things better, to develop my own skills and how to work in group. At least I think it’s important that problem-based learning is implemented in a good and thoughtful way, otherwise it will lose its value.
ce in a town or in a rural area. What would you choose and why? I prefer a practice in a town. I like living in a city because of its atmosphere and dynamics. Also I think as a clinician I will face a more variable patient population. In terms of work organization I think working in an urban area offers more options in terms of working with multidisciplinary teams eg health programs, schools, preven3. What part of your study was the most tion programs,… educational to you, what was the best learning experience in your studies (e.g. in- 5. Do you ever get in touch with the comternship, research or being ill yourself)? munity? Through my studies I got in touch with seUntil now we’ve had only lectures and veral health practices in my community. some practicals. Some of these lectures are Specifically I did an educational program quite good to remember because they gave about health food and lifestyle in children, me a lot of knowledge that I can use in my pregnant and lactating women. future career. The best learning experience Every year a fellow student and I organize a in the past were my internships as a dieti- healthy day for children in a local commutian. These internships helped me under- nity school. In a playful way we introduce stand my theoretical knowledge better. But healthy lifestyles to children. most of all I will remember contact with the Another project I was involved in was an patients. It gives me a great feeling to be obesity project for children in a general really able to help people. I’m also looking hospital. For this project, pediatricians, phyforward to participating in the Network: siotherapists, psychologists and dieticians TUFH conference in Ayutthaya, this will be worked together in a multidisciplinary way! for sure a great educational and learning And finally in the context of my bachelor experience! proof I developed educational material to educate pregnant and lactating women 4. Imagine if you were to choose: a practi- about healthy food and lifestyle during this period. 25
Member and Organisational News Messages from the Executive Committee EC eminences: John Hamilton We had the exceptional opportunity to meet with Dr John Hamilton, Emeritus Professor at the University of Newcastle in Australia. Dr Hamilton is one of our Network’s “Grey Eminences”, one of the founders of what The Network: TUFH is today! Who can better introduce him than the man himself: Can you explain to our readers who might not know who you are? I’m English originally, now living in Australia, a physician qualified in 1960 so I’m one of the old boys. I have been involved in medical education since being a member of the team that started McMaster University. At different times I chaired student selection and the curriculum as a whole. I had African mission hospital experience in Zambia and after McMaster we (my wife Alison and our two children aged five and six), relocated for three and a half years to Ilorin in Nigeria and set up the curriculum of a new medical school under the Deanship of Professor Eldryd Parry, a founding leader of the Network. Core to relevant education was community engagement through living in village community for a month every year. This expressed “social accountability” without using or even knowing this more new title. I’ve recently met many Ilorin current students and also graduates, up to 30 years after their graduation. They feel very strongly that their “community engagement” (another recent phrase) had given them a sense of professional direction. I was Dean of Medicine of Newcastle University in Australia, again a third founding member of the Network. For 14 years I led that school. I set up the accreditation system in Australia and chaired the World Health Diarrheal Diseases Program. That led me to get a lot more involved in global things. The, in 2000 we returned to England to set up a new medical school at Durham University in partnership with Newcastle, England. And there we did the same thing as we did in Ilorin, but now in a large socially disadvantaged urban and industrial setting. Again, a recent visit to students and graduates has confirmed the positive and widening impact their community engagement has had on their professional development. Now I’m supposed to be retired but still running the last 2 years of our curriculum in Newcastle and I’m engaged in international support for medical education, in Africa particularly, in Iran and several other countries.
I have not been able to attend this meeting for the last three three years for various external reasons. It is very encouraging now come back and see such a wide range of creative activity and a cross fertilizations of ideas. You were involved in one of the founding universities of The Network:TUFH, how did it all start in the beginning? There were about 8 medical schools back in 1979, all of whom where innovative, and they formed a network. Our first title was The Network of Innovative Medical Schools, Mc Master, Maastricht, Ilorin in Nigeria, Newcastle, Cuba, the Suez Canal University in Egypt and a number of other schools. They all were breaking into new ground in terms of learning and community engagement, selection of students and problem based learning. The Network provided for cooperation and exchange of views. Meetings occurred annually and working parties sustained initiatives as time went on. The name changed, it later became Community Oriented, and later “Towards Unity for Health” when it took responsibility for the WHO initiative led by Charles Boelen. The profile of membership also expanded with these changes, not hugely but always had a global networking extremely helpful in both directions. Developed countries are much slower to move generally than developing countries; they are more cautious. How in your opinion did the network change over the years? Whereas in the beginning it was the Deans that were usually leading the governing body now engages wider groups with more educationalists and , after some hesitation, members of other health professions. It has formed task forces on a number of things like social accountability, public health and medicine, women’s health. Its publication has matured and developed, that’s a very good means for people in developing countries to launch what they are doing.
It grew gradually and in the last 2 decades it has been a prominent part. The difficulty is the continuity because students soon move on, but these student groups in some of the medical schools are very active and very well organized.
Keep your eyes wide open to the rest of the world. What are according to you the challenges for the future of The Network: TUFH? I think it needs to strengthen the membership that has sunk a bit. It needs to make sure that some of the taskforces move on more securely into operational programs. It should capitalize on the liaising with some of the other partners who have together established at this conference a wide field for cooperation. An example is THEnet (Training for Health Equity), a closely co-operative groups of schools, researching and expanding educational aspects of community engagement and service to disadvantaged communities. This gives them a clear sense of direction and developing co-operative research. You don’t always need external funding; you may have to do it through your internal funding and governance. Wider scale initiatives usually do need additional support and it is an aim of some of the organizations and donors at this conference to generate ways of sourcing funds. As a wise founder of this network, if you could give one advice to young people, what would it be? Seek responsibility in your health professional education, if you do not gain responsibility you cannot develop the security and depth of insight that you need to go forward and to be both creative and effective! Keep your eyes wide open to the rest of the world. Make sure that what is being done is evaluated dispassionately, but not just by measurement; there is a larger sphere of professional development and altruism to be taken into account!
John Hamilton, Emeritus Professor, Faculty of Has student involvement always been as im- Health, The University of Newcastle, Australia Email: John.hamilton@newcastle.edu.au portant as today? 26
Member and Organisational News Taskforces Newest Task Force Leading the WHO’s Implementation of Guidelines for Transforming and Scaling Up of Health Professionals Education and Training Recognizing that not only is there a growing insufficient number of health professionals worldwide, there is a more growing concern of the lack of quality and relevance of their education to meet the current and future health needs of local populations. This has prompted the need to create a Task Force to implement the WHO’s recent publication of a robust set of recommendations. TUFH welcomes the Task Force membership and its’ Chair, Sue Berry of the Northern Ontario School of Medicine. This Task Force, working collaboratively with the World Health Organization, is addressing and strategizing the implementation of the recent publication and recommendations of “Guidelines for Transforming and Scaling Up Health Professionals Education and Training” (http://www.the-networktufh.org/ about/taskforces/implementation-transforming-health-professionalseducation-and-training-guidelines). Coined by Celetti et al (2011) who define transformative scale up health professionals education and training as being the “sustainable expansion and reform of health professional educational and training to increase the quantity, quality, and relevance of health professionals and in doing so strengthen country health systems and improve population health outcomes. From an around the world perspective, membership currently exists from the six organizations of The Network: Towards Unity for Health (TUFH); Consortium of Longitudinal Integrated Curricula (CLIC); Flinders University; Northern Ontario School of Medicine (NOSM); Training for Health Equity (THEnet); World Health Organization (WHO); and the Wonca Rural Working Party. The collective and collaborative efforts of this group will begin to address and implement practical strategies and activities for each of the recommendations set forth in the WHO recent publication. WHO, in 2011, garnered perspectives from leaders from around the globe resulting in a consensus that training more health professionals was not the sole answer in addressing a global health care system suffering the vexing issues of shortages and lack of access and equity to health care. Rather, creating a vision for bringing about greater alignment between educational institutions and health care systems, country and community ownerships of priorities and fostering social accountability as combined efforts of educational institutions and communities for local relevance in research and education, was a more robust and sustainable approach for creating infrastructures of learning environments and the retention of high quality faculty to teach. The Guidelines provide interventions falling into five specific categories, those being: education and training institutions, accreditation and regulation, financing and sustainability, monitoring, implementation, and evaluation and governance and planning. We invite you to review our Task Force Term of Reference on our website (http://www.the-networktufh.org/ about/taskforces/implementation-transforming-health-professionals-education-and-training-guidelines) and consider sharing with TUFH Secretariat (Secretariat-network@ugent.be) your or your organization’s interest in becoming a member. The Task Force will be meeting in Ayutthaya Thailand at The Network: TUFH’s annual conference and certainly look forward to you joining our meeting and lively discussions. Sue Berry, Chair Email: sberry@nosm.ca
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Member and Organisational News Taskforces
Updates from the Women and Health Taskforce The Women & Health Taskforce (WHTF) includes a core group of women’s health advocates from Mexico, Egypt, Sudan, Nigeria, Uganda, South Africa, India, Pakistan, Nepal, and Malaysia. At the most recent Network meeting in Thunder Bay, the WHTF partnered with the Ontario Native Women’s Association (ONWA) to host a screening of Unnatural and Accidental. The film, which discussed themes of violence against Aboriginal women, fostered great discussion on the health needs of underserved Aboriginal populations across Canada. The WHTF also hosted two major workshops in Thunder Bay, one discussing Adolescent and Reproductive Health in the US, Mexico, Sudan, Nepal, and India, and the other discussing Maternal and Reproductive Health in India, Haiti, and South Sudan.
The WHTF continues its work on producing the 3rd edition of the Women and Health Learning Package (WHLP), a series of modules on women’s health topics. In addition to the work that taskforce members have been doing to update the modules and cases, the taskforce has also partnered with Hesperian Health Guides to work towards promoting health education materials. The taskforce looks forward to partnering with a local Thai women’s health organization to highlight the important work being done in Thailand to reduce maternal and child health. Hope to see you at many Women’s Health events in Ayutthaya! Meenakshi Menon, co chair, WHTF Email: mmenon@ghets.org
Interprofessional Education Task Force (IPE) There are lots of developments taking place internationally in interprofessional education right now, particularly in America, Canada, Australia, New Zealand, the Philippines, Columbia, Africa and starting in India. So much has happened and been published over the last few years that I have updated the Interprofessional reference list for the web site. A few key ones are: • American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Association, Association of American Medical Colleges and Association of Schools of Public Health (2011) Core Competences for Interprofessional Collaborative Practice: Report of an Expert Panel. • Canadian Interprofessional Health Collaborative (2012) Inventory of Quantitative Tools to Measure Interprofessional Education and Collaborative Practice. • Canadian Interprofessional Health Collaborative (2010) A National Interprofessional Competency Framework. Vancover. • Cerra, F. and Brandt, C. F. (2011) Renewed focus in the United States links interprofessional education with redesigning health care Guest Editorial: Journal of Inter28
professional Care November 2011, Vol. 25, No. 6 , 394396 (doi:10.3109/13561820.2011.615576). • Thistlethwaite, J. (2012) Values-based Interprofessional Collaborative Practice: Working Together in Health Care Cambridge University Press. If you review the full list and know of any more publications which should be added please do let me know. Of course we hope many of the latest developments will feature this year in the special issue of Education for Health which will be published later this year. We had 16 abstracts which we accepted for the special issue and whilst not all of this can appear in one issue we hope that those which don’t appear in the special issue will be published in later issues so we can ensure we have a source of regular updates on community oriented interprofessional activities. The 2013 Network: Towards Unity for Health conference in Thailand will again highlight interprofessionalism as a theme, so please do get your abstracts in early, and we look forward to seeing you there. Professor Dawn Forman and Professor Betsy VanLeit CoChairs of the Task Force for Interprofessional Education Email: dawn@ilmd.biz
Member and Organisational News Taskforces Social Accountability and Accreditation The Taskforce Social Accountability and Accreditation (TFSAA) held a number of workshops and networking meetings during Rendezvous 2012 in Thunder Bay. In keeping with the modus vivendi of the Network: TUFH as a network rather than a formal structure with rigid committee membership, these meetings embraced a number of individuals and organizations ranging from THEnet, the Global Consensus on Social Accountability (GCSA), WONCA Rural, the LCME, the Society of Rural Physicians of Canada, GHETS, the Association of Faculties of Medicine of Canada (AFMC), the Patan Academy of Health Sciences and various other national and international perspectives on relevant work. Since that time Drs Boelen, Gibbs and Woollard have been extensively involved in presentations, workshops and linkages with existing and emerging accreditation systems throughout the world. While not always under the imprimatur of the TFSAA this work has continued to advance the strategic direction initially outlined at the Kampala meeting. The GCSA has translated the Consensus into seven languages and these are available at www.healthsocialaccountability.org. Unfortunately the World Federation for Medical Education (WFME) meeting planned for review of their standards had to be postponed but members of the TFSAA are connected with the ongoing process and the concepts and aspirations of social accountability have been injected into the deliberations. We are connected with the evaluation developments of THEnet and with the ASPIRE initiative of the Association of Medical Education in Europe (AMEE). There is very active work in South East Asia, the Francophone and Arabic worlds and in North Africa. As we look forward to the meeting in Thailand this fall, we will have further activities to report as well as a repository of relevant work to provide an opportunity for the TFSAA to more formally review its accomplishments and revisit the strategic plan. This provides an opportunity to develop the next stages of activity with selected accreditation systems, organizations and institutions that are moving forward firmly in the direction of social accountability. We hope to see many members there to contribute at this important juncture for the TFSAA.
We also like to draw your attention to a recent publication by one our co-chairs in Education for Health:
The Social Accountability of Medical Schools and its Indicators Charles Boelen, Shafik Dharamsi, Trevor Gibbs ABSTRACT Context: There is growing interest worldwide in social accountability for medical and other health professional schools. Attempts have been made to apply the concept primarily to educational reform initiatives with limited concern towards transforming an entire institution to commit and assess its education, research and service delivery missions to better meet priority health needs in society for an efficient, equitable an sustainable health system. Methods: In this paper, we clarify the concept of social accountability in relation to responsibility and responsiveness by providing practical examples of its application; and we expand on a previously described conceptual model of social accountability (the CPU model), by further delineating the parameters composing the model and providing examples on how to translate them into meaningful indicators. Discussion: The clarification of concepts of social responsibility, responsiveness and accountability and the examples provided in designing indicators may help medical schools and other health professional schools in crafting their own benchmarks to assess progress towards social accountability within the context of their particular environment. Charles Boelen and Bob Woollard, Co-Chairs Email: Email: woollard@familymed.ubd.ca/boelen.charles@wanadoo.fr
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Member and Organisational News Taskforces
Integrating Public Health and Medicine
The Integrating public health and medicine task force has been rather quiet recently. In the past the Conferences period attracted interested professionals to the discussion and actions. For administrative reasons, the task force meetings attracted only a small number of people during the last two conferences. It is hoped that the meeting in Ayutthaya will help revive the group. Nonetheless, there are interesting initiatives going on. For instance, the University of New Mexico School Of Medicine now integrates public health in all four years of their curriculum and students receive a public health certificate on graduation. On a broader basis, both the Association of Faculties of Medicine in Canada and the American Association of Medical Colleges have been working on developing public health learning tools and on promoting public health among students. The two organizations are now discussing how they can collaborate on their common goals. In addition, a positive sign for the future, is the increase number of undergraduate public health learning in the U.S. that are on the way to be accepted by many undergraduate 4-years institutions. Perhaps the main challenge to the integration of public health and medicine is the fragmentation of health care which forces the distinction between the two. It also influences the practice of medicine, so that, as practitioners, teachers themselves may find it difficult to inte-
grate public health and teach from an integrated practice. This separation of medicine and public health (as the fragmentation) is expressed as a vicious circle by which academic institutions face difficulties to find an appropriate setting practicing integration for training students and professionals, while the health organizations have problems to engage in integrated services where there are not enough trained professionals to cover those functions. Furthermore, in the current financial climate, support to implement change can be difficult to find. The task force sees solutions to these challenges in developing an active network that can identify or share learning resources aimed at teachers of medicine as well as students, approaches to faculty development and examples of best practice. The chair of the task force will lead the development of a position paper looking at challenges and opportunities. The Task Force may capitalize on these developments, and maybe to work around the professionals who may participate in the specific mini-workshops. In the past communications with Deans of Medical Schools in the Network didn’t result in an increase involvement. Denise Donovan, Jaime Gofin; Co-Chairs Email: Denise.Donovan@USherbrooke. ca; jgofin@unmc.edu
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Member and Organisational News Education and Research The Wall of Fame In this new section we want to pay more respect to all those active members, publishing valuable articles. Hereunder you can find a summary of relevant articles for our network. Ezeala CC, Ezeala MO, Swami N. Strengthening admissions policy into health professions education: Focus on a premier Pacific Island medical college. Journal of Educational Evaluations for the Health Professions; 2012;9:11. Ezeala CC, Swami NS, Lal N, Hussain S. Admission scores as a predictor of academic success in the Fiji School of Medicine. Journal of Higher Education Policy and Management 2012; 34(1): 61-66. Ezeala CC, Ezeala MO, Nweke IN. Common errors in manuscripts submitted to medical science journals. Annals of Medical and Health Sciences Research 2013. Giri A, Khatiwada P, Shrestha B, Chettri RK. Perceptions of government knowledge and control over contributions of aid organizations and INGOs to health in Nepal: a qualitative study. Global Health. 2013 Jan 18;9:1. Omotara Babatunji, Yahya,Shuaibu, Amodu, Mary, Bimba, John (2012). Awareness, attitude and practice of rural women regarding breast cancer in northeastern Nigeria. Journal of Community Medical Health Education 2012, 2:5. Omotara, BA Tamunoibuomi F. Okujagu, Samuel O. Etatuvie, Omeiza Beida, & Eric Gbodossou. Assessment of Knowledge, Attitude and Practice of Stakeholders towards Immunization in Borno State, Nigeria: A Qualitative Approach. Journal of Community Medical Health Education 2012. Clithero, A., Sapien, R., Kitzes, J., Kalishman, S., Wayne, S., Solan, B., Wagner, L., and Romero-Leggott, V. (2013) “Unique Premedical Education Experience in Public Health and Equity: Combined BA/MD Summer Practicum.” Creative Education/ Higher Education July. Johannesson, E., Hult, H. Abrandt Dahlgren, M. (2012) Simulating the real: Manual Clinical Skills Training. Conditions and Practices of Learning Through Simulation. Realising Exemplary Practice-Based Education. 187-194; Rotterdam: Sense (Textbook). Abrandt Dahlgren, M., Dahlgren, L.O. & Dahlberg, J (2012) Learning professional practice through education. Practice, Learning and Change: practice-theory perspectives on professional learning, 183-199. Dordrecht: Springer (Textbook). Kavya Sharma, PGHHM; Sanjay Zodpey, PhD; Abhay Gaidhane, MD; Zahiruddin Quazi Syed, MD. Rajeev Kumar, MD; Alison Morgan, PhD; Designing the Framework for Competency-Based Master of Public Health Programs in India; Journal of Public Health Management Practice, 2013, 19(1), 30–39. Hudson JN, Weston KM, Farmer EA. Medical students on long-term placements: what is the financial cost to supervisors? Rural Remote Health 2012;12: 1951. Kiguli-Malwadde E, De Maeseneer J, Kanssime C. Developing family medicine in Africa. Africa Health. May 2013. Vol 35 No 4, 27-29. 31
Member and Organisational News Introducing Members New Members Our Network keeps on growing, this year we welcome the following new members: Dr. Constance Dimity Pond, Faculty of Health, University of Newcastle, Callaghan, NSW, Australia
Full Members University of Connecticut, School of Medicine, Department of Community Medicine and Pediatrics, Farmington, CT, United States of America
Dr. Lionel Green Thompson, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Republic of South Africa
University Eduardo, Mondlane, Faculty of Medicine, Maputo, Mozambique
Associate Members
Dr. Karl Stobbe, Faculty of Health Sciences, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Canada
University of Medical Sciences and Technology, Graduate College, Reproductive and Child Health Research Unit, Khartoum, Sudan
Mrs. Jill Allison, Faculty of Medicine, Memorial University of Newfoundland, Memorial University of Newfoundland, Canada
High Institute of Health Sciences, Sana’a, Yemen
Dr. Mpho Mogodi, Facutly of Health Sciences, University of Botswana, School of Medicine, Gaborone, Botswana
Comprehensive Rural Health Project, Jamkhed, India
Dr. Carme Carrion, Medical School Medicina, University of Girona/Fundació UdG Medicina, Girona, Catalunya, Spain
Individual Members Dr. Emmanuel Abara, Faculty of Medicine, Northern Ontario School of Medicine/Kirkland & District Hospital, Richmond Hill, Ontario, Canada
Dr. Zarrin Sidiqui, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia
Newsletter Volume 31/no. 1/June 2013 ISSN 1571-9308 Editor: Julie Vanden Bulcke Language editor: Amy Clithero The Network: Towards Unity for Health Publications UGent University Hospital, 6K3 De Pintelaan 185 B-9000 Ghent Belgium Tel: (32) (0)9 332 1234 Fax: (32) (0)9 332 49 67 Email: secretariat-network@ugent.be Internet: www.the-networktufh.org Lay Out: Marijke Deweerdt, Sofie De Backere Print: Drukkerij Focusprint
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