Lessons from studies in South Asia and Sub-Saharan Africa on improvement of basic medical education and related health services
Main Article Content
Abstract
South Asia and Sub-Saharan Africa are facing rapid proliferation of medical schools especially in the private sector stimulated by demand for doctors in the mainly curative private health sector. Accreditation has failed to stem declining standards of basic medical education and its increasing irrelevance to national health care needs. Medical graduates tend to opt for careers in high paying specialties and frequently migrate to Western countries for career progression and a better organized lifestyle.
However, some recent developments hold promise for improvement and are potential solutions to the problem: (a) the trend towards decentralization of health systems favours strengthening of district health services that hold the key to serve populations equitably, with district hospitals as hubs for integrating clinical care and Primary Health Care; (b) the trend towards diversification of basic medical education to district health services is potentially beneficial for both as they are interdependent; and (c) the realization that accreditation of health professional education must influence health outcomes through practice provides the impetus to improve related health services.
The aim of the present review was to find evidence of successful implementation of these measures in South Asia and Sub-Saharan Africa.
Evidence of improvements in performance and health outcomes from decentralization of health systems and strengthening of district health services is forthcoming, although provision and management of human and financial resources are challenging. Similarly, there is growing evidence from Sub-Saharan Africa that improvement of health professional education and quality of health care occurs when experiential learning is based at district level hospitals and its related health services; albeit the evidence is presently limited to externally supported projects.
Accreditation based on successful integration of medical education and health services, is the weakest link. Although there is growing pressure for national accreditation agencies to implement global standards of basic medical education, without the context of professional development associated with coordinated improvement in related health services the notion that global standards will improve health care lacks credibility.
Eventually, effective convergence of these measures is required if the daunting health challenges in South Asia and Sub-Saharan Africa are to be addressed sustainably.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. Tackett S, Zhang C, Nassery N, Caufield-Noll C, van Zanten M. Describing the evidence base for accreditation in undergraduate medical education internationally: a scoping review. Acad Med 2019;94:1995-2008. DOI 10.1097/ACM.0000000000002857
3. Tackett S. Examining the Educational Commission for Foreign Medical Graduates announcement requiring medical school accreditation beginning in 2023. Acad Med 2019;94:943-9.DOI : 10.1097/ACM.0000000000002675
4. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Glob Health 2018;6:e1196-1252. DOI https://doi.org/10.1016/S2214-109X(18)30386-3
5. Roder-DeWan S, Gage A, Hirschhorn LR, et al. Level of confidence in and endorsement of the health system among internet users in 12 low-income and middle-income countries. BMJ Glob Health 2020;5:e002205. DOI: http://dx.doi.org/10.1136/bmjgh-2019-002205
6. Bukhman G, Mocumbi AO, Atun R, et al. The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion. Lancet 2020; 396(10256):991-1044. DOI: https://doi.org/10.1016/S0140-6736(20)31907-3
7. Rajbhandari R, McMahon DE, Rhatigan JJ, Farmer PE. The neglected hospital-the district hospital's central role in global health care delivery. N Engl J Med 2020; 382:397-400. DOI: 10.1056/NEJMp1911298
8. Leslie HH, Spiegelman D, Zhou X, Kruk ME. Service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania. Bull World Health Org 2017;95:738. DOI: 10.2471/BLT.17.191916
9. Kruk ME, Gage AD, Joseph NT, Danaei G, Garcia-Saiso S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet 2018;392(10160):2203-12. DOI: https://doi.org/10.1016/S0140-6736(18)31668-4
10. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386(9993):569-624. DOI: https://doi.org/10.1016/S0140-6736(15)60160-X
11. Dwicaksono A, Fox AM. Does decentralization improve health system performance and outcomes in low- and middle-income countries? Milbank Q 2018; 96 (2):323-368
12. Munoz DC, Amador PM, Llamas LM, Hernandez DM, Sancho JMS. Decentralization of health systems in low- and middle-income countries: a systematic review. Int J Public Health 2017;62:219–229 DOI 10.1007/s00038-016-0872-2
13. Hatt L, Johns B, Connor C, Meline M, Kukla M, Moat K. Impact of health systems strengthening on health. The Health Finance and Governance Project 2015; Abt Associates, Bethesda.
14. World Health Organization. The hospital in rural and urban districts: report of a WHO study group on the functions of hospitals at the first referral level [meeting held in Geneva, 30 October-5 November 1990]. World Health Organization; 1992.
15. Zaidi S, Saligram P, Ahmed S, Sonderp E, Sheikh K. Expanding access to healthcare in South Asia. BMJ 2017 11;357. DOI: https://doi.org/10.1136/bmj.j1645
16. Crisp N, Chen L. Global supply of health professionals. N Engl J Med 2014;370:950-7. DOI: 10.1056/NEJMra1111610
17. Dreyer AR, Rispel LC. Context, types, and utilisation of decentralised training platforms in undergraduate medical education at four South African universities: Implications for universal health coverage. Cogent Education 2021;8:1906493. DOI: https://doi.org/10.1080/2331186X.2021.1906493
18. de Villiers M, van Schalkwyk S, Blitz J, et al. Decentralized training for medical students: a scoping review. BMC Med Educ 2017;17:196 DOI 10.1186/s12909-017-1050-9
19. Putri LP, O’Sullivan BG, Russell DJ, et al. Factors associated with increasing rural doctor supply in Asia-pacific LMICs: a scoping review. Human Resour Health 2020;18:93 https://doi.org/10.1186/s12960-020-00533-4
20. Talib Z, van Schalkwyk S, Couper I, et al. M. Medical education in decentralized settings: How medical students contribute to health care in 10 sub-Saharan African countries. Acad Med 2017;92:1723. DOI: 10.1097/ACM.0000000000002003
21. Cancedda C, Farmer PE, Kyamanywa P, et al. Enhancing formal educational and in-service training programs in rural Rwanda: a partnership among the public sector, a nongovernmental organization, and academia. Acad Med 2014;1117–1124. DOI: 10.1097/ACM.0000000000000376/
22. Leshabari S, Lubbock LA, Kaijage H, et al. First steps towards interprofessional health practice in Tanzania: An educational experience in rural Bagamoyo district. J Public Health Policy 2012 (December) 33:S138–S149
23. Eichbaum Q, Hedimbi M, Bowa K, et al. New medical schools in Africa: challenges and opportunities. CONSAMS and the value of working in consortia. Ann Glob Health 2015; 81(2):265-269. ISSN 2214-9996 http://dx.doi.org/10.1016/j.aogh.2015.03.005
24. Baral KP, Upadhyay SK, Bhandhary S, Gongal RN, Karki A. Development of community-based learning and education system within undergraduate medical curriculum of Patan Academy of Health Sciences. J Nepal Health Res Counc 2016 Jun 6; 14(32):58-65
25. Prihatiningsih TS, Kamal Y, Woollard R, Fisher J, Abdalla ME, Boelen C. Social accountability and accreditation: impacting health system performance and population health. Social Innovations Journal 2020 Sep; 18:3.
26. Frank JR, Taber S, van Zanten M, Scheele F, Blouin D. The role of accreditation in 21st century health professions education: report of an International Consensus Group. BMC Med Educ 2020;20(Suppl.1):305 https://doi.org/10.1186/s12909-020-02121-5
27. Pakistan Medical Commission. PMC Medical and Dental Undergraduate Education (Admission, Curriculum and Conduct) Regulations 2021.pdf
28. Weisz G, Nannestad B. The World Health Organization and the global standardization of medical training, a history. Glob Health 2021; 17:96 https://doi.org/10.1186/s12992-021-00733-0
29. Mishra GV, Shrivastava T, Waghmare L, Patwa PA, Singh RK. Current status of accreditation of medical education: a systematic review. Journal of Krishna Institute of Medical Sciences University 2021;10(4):1-12
30. Biggs JSG. The social responsibilities of medical colleges in Pakistan. J Coll Physicians Surg (Pakistan) 2013;23(1):24
31. Solanki A, Kashyap S. Medical education in India: current challenges and the way forward. Med Teach 2014; 36(12):1027-1031.
32. Khan AW, Sethi A, Wajid G, Yasmeen R. Challenges towards quality assurance of basic medical education in Pakistan. Pak J Med Sci 2020; 36(2):4-9. Doi; https://doi.org/10.12669/pjms.36.2.1319
33. Pandya H, Chacko T, Mohammed CA. Regulatory system to promote the culture of quality at Indian medical schools: are we doing enough? Natl Med J India 2021; 34(5):298-301.
34. Rafi A, Anwar I. Challenges for implementing WFME standards for accreditation in health professions education in low-middle-income countries: a scoping review. J Pak Med Assoc 2021; 71(3):966-976.
35. Drislane FW, Akpalu A, Wegdam HHJ. The medical system in Ghana. Yale J Biol Med 2014; 87:321-326.
36. Adhikari B, Mishra SR. Urgent need for reform in Nepal medical education. Lancet 2016; 388:2739-2740.
37. Raman SK. Medical education in India. The Asia Pacific Scholar 2018; 3(2):55-57.
38. Galukande M, Opio K, Nakasujja N, et al. Accreditation is a sub-Saharan medical school: a case study at Makerere University. BMC Med Educ 2013; 13:73
39. Olopade FE, Adaramoye OA, Raji Y, Fasola AO, Olapade-Olaopa EO. Developing a competency-based medical education curriculum for the core basic sciences in an African medical school. Adv Med Educ Pract 2016;7:389–398
40. Child MJ, Kiarie JN, Allen SM, et al. Expanding clinical medical training opportunities at the University of Nairobi: adapting a regional medical education model from WWAMI program at the University of Washington. Acad Med 2014; 89(80):S35-S39. Doi:00.1097/ACM.0000000000000350
41. Begum S, Talukder MHK. Opinion of policy makers regarding the need of ‘global accreditation’ of undergraduate medical education in Bangladesh. Bangladesh Journal of Medical Education 2016; 7(2):9-16.
42. Karunathilake IM. The concept, application and relevance of minimum standards of medical education. South-East Asian Journal of Medical Education 2016; 10(2):1-3.
43. Al Mahdi TAS. Overview of the course of undergraduate medical education in the Sudan. Sudan Journal of Medical Sciences 2019; 14(4):188-201. DOI 10.18502/SJMS.v14i4.5899
44. World Federation of Medical Education. Global Standards for Quality Improvement 2015 – BME: WFME Standards for Basic Medical Education; https://wfme.org/download/wfme-global-standards-for-quality-improvement-bme/.
45. Abraham Y, Ajaze A. The new innovative medical education system in Ethiopia: background and development. Ethiop J Health Dev 2013; 27 Special Issue 1:36-40.