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REVIEW

Establishing Medical Schools in Limited Resource Settings

Tsinuel Girma1, Tsedeke Asaminew2, Matthias Siebeck3,4, Martin R. Fischer5, Fabian Jacobs3,4, Sebsibe Desalegn6, Yoseph Mamo7, Abraham Haileamlak1, and participants of the International Workshop in Bishoftu, Ethopia in November 20138

ABSTRACT

INTRODUCTION: One urgent goal of countries in sub-Saharan Africa is to dynamically scale up the education and work force of medical doctors in the training institutions and health facilities, respectively. These countries face challenges related to the rapid scale up which is mostly done without proper strategic planning, without the basic elements of infrastructure development, educational as well as academic and administrative human resources. Medical education done in the context of limited resources is thus compromising the quality of graduates. In the future, a collaborative and need-based approach involving major stakeholders such as medical educators concerned, ministries, planners and policy makers is needed. GOAL: This article identifies the challenges of establishing medical schools and sustaining the quality of education through rapid scale-up in Sub-Saharan Africa in the settings of limited resources. It also outlines the minimum requirements for establishing medical schools. METHODS: A consensus building workshop was conducted in Bishoftu, , from Nov 8-12,2013. Participants were professionals from 13 Ethiopian medical schools, and representatives of medical schools from South , Somaliland, , and . Participants are listed in Appendix 1. RECOMMENDATIONS: The governments and stakeholders should jointly develop strategic plans and a roadmaps for opening or expanding medical schools to scale up educational resources. It is advisable that medical schools have autonomy regarding the number of student-intake, student selection, curriculum ownership, resource allocation including for infrastructure and staff development. Health science and medical curricula should be integrated within and harmonized nationally. An educational evaluation framework needs to be embedded in the curricula, and all medical schools should have Health Science Education Development Centers

DOI: http://dx.doi.org/10.4314/ejhs.v26i3.10

INTRODUCTION (FMOH, Ethiopia). In Ethiopia for instance, infectious and communicable diseases account for Most sub-Saharan countries including Ethiopia, about 74% of deaths, and 80% of DALY1 Somalia, Somaliland, and HIV/AIDS and malaria remain as the Mozambique have poor health status profiles

1College of Health Science, Jimma University; Jimma, Ethiopia 2Department of Ophthalmology, Coordinator of Health Sciences and Medical Education Development Center, College Health Science, Jimma University; Jimma, Ethiopia 3Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Ludwig-Maximilians-University Hospital, Germany 4Center for International Health, Ludwig-Maximilians-University, Munich, Germany 5Institute for Medical Education, University Hospital and Medical Faculty, Ludwig-Maximilians-University, Germany 6 Yirgalem Hospital Medical College, Ethiopia 7 Jimma University Chronic Disease Project, Ethiopia 8cf. List of participants in Appendix 1 Corresponding Author: Dr Tsedeke Asaminew Alemu, Email: [email protected]

278 Ethiop J Health Sci. Vol. 26, No. 3 May 2016 major causes of morbidity and mortality. The government. Approval of proposals following a maternal mortality ratio of 470/100,000 live births tedious review at internal and external consultancy and infant mortality of 67/1000 stand higher than is mandatory before construction or acquisition of these cases in many countries. This situation is buildings (1,6). The time it takes for completion of further aggravated by the high annual population these processes may vary under different growth, approximated to 2.7%. The average life circumstances, but it is often not short. However, expectancy at birth in Ethiopia is about 58 years establishment of regional or branch campuses of (1,2). All these indices were even very lower than existing medical schools may reduce the length of this just two decades ago. time to implement and help contain overall costs Although the practice of western medicine in (7). In ideal situations, the launching of medical Ethiopia dates back to 1520s, organized and school should follow accreditation by an sustainable modern medical practice started only appropriate national or sub-national regulatory after around 1896 (3,4). The overall potential of body. health service coverage in 2008 was estimated at Expansion of medical schools is necessary 89.6%, a 25.6% increase compared to 1996 (4). but not a sufficient solution alone to address the Much of the rural population in the region have rapidly growing demand for health care work had no access to or has been far from modern force. Considering the number of years of health care, leading to inability of the health care physician training requires (mostly 6 years), delivery systems to respond both quantitatively and planning has to balance between preparing for the qualitatively to the health needs of the people. One ideal system and accommodating current health urgent goal of countriesin the sub-Saharan Africa care use patterns. From current experience, is therefore to scale-up the education and work planning for an ideal health care system alone force of medical doctors in the training institution cannot address the actual needs of the population and health facilities, respectively. Such a scheme (8). The planning should also include forecasting has forced the health system to hire more medical for future graduates proportion staying in the doctors. However, the number of physicians in health care delivery system. The issue of brain service is still very low compared with the actual drain and internal and external migration should need in the 23 years period (1984-2006). The not be forgotten (9,10), reminding the highest and lowest physician to population ratios in inclusiveness in the planning of motivation and the public sector were found to be in 1989 retention as well as attractive career development. (1:28,000) and 2006 (1:118,000), respectively (5). Most medical schools, especially those in In response to the growing demand for health South-East Asia, are currently experiencing work force, countries in Africa like Ethiopia are difficulties in providing the right quality and establishing public medical schools at rapid pace quantity of educational experiences as the curricula adding to the very few existing schools which use have failed to respond to the needs of the conventional teaching philosophy. For example, community and the country. The traditional since 2004 more than 20 medical schools were approach of education was determined by mostly founded implementing either integrated or hybrid teacher-centered methods such as lecturing and medical curriculum. Private medical schools are lack of outcome and competency orientation. The also contributing to this rapid scale-up (1). pedagogic shift from this traditional approach to an Generally, establishing medical school is a outcome-based approach driven by the needs of the challenging task. It requires a series of steps health care system requires a fundamental change including addressing the need and assessing of the roles and commitments of educators, resources along with their costs for the planners and policy makers (11,12).

1DALY is a health gap measure that extends the concept of potential years of life lost due to premature death (PYLL) to include equivalent years of “healthy” life lost by virtue of being in states of poor health or disability (1). DALYs for a disease or health condition are calculated as the sum of the years of life lost due to premature mortality (YLL) in the population and the years lost due to disability (YLD) for incident cases of the health condition.

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Medical school curriculum development for a education and focused on the structure and developing country should be firmly based on function of medical schools including educational community and public health, reflect the medical procedures, duration of programs, facilities, problems of the country, enable joint teaching by number of staff available for instruction, and other different departments especially in the basic resources necessary to provide educational medical sciences, and allow for more economic experiences for students. and flexible use of staff and teaching facilities. If Research done in sub-Saharan countries possible, the clinical disciplines should be reported that graduates from medical schools in introduced to students during their study of basic sub-Saharan Africa are 10,000–11,000 per year. medical sciences, wide access to information Differences between enrolment and graduation should be provided, and self-directed learning figures are mainly attributable to the opening or encouraged (12,13). expansion of schools. A few universities admit The core medical curriculum consists of the large numbers of students before numbers are fundamental theory and practice of medicine. And reduce themin the second year. Fifty nine of 84 specifically consists of basic biomedical, (70%) responding schools reported that at least behavioral and social sciences, general clinical 80% of first-year students graduate (16). skills, clinical decision skills, communication The Ethiopian Government is investing abilities and medical ethics. All these must be greatly in a workforce scale up plan based on a so- addressed by medical schools which aim to called flood and retains strategy, which involves a produce safe practitioners of quality (14). Teaching rapid, massive increase in the number of trained and learning methods moved from traditional, health workers and attendant retention measures. teacher-centered education to one that is The Ministry of Education mandated all medical fundamentally student-centered and outcome- schools to expand their class sizes. Thus, Jimma oriented. The use of problem based learning University’s (Ethiopia) first-year enrolment for (PBL), small group and collaborative learning 2009 increased from 200 to 250, and is expected to models as well as community-based education and reach 350 for 2011. Actually, the 2013 admission service have formed the key pedagogical elements was 400 students. The government supports this of medical education (9). Whereas many countries strategy by investing in physical infrastructure, have established national systems for the including construction of a new teaching hospital assessment of quality in higher education, some at the university. The Hubert Kairuki Memorial low-income countries have not fully developed University in exemplifies private sector such systems. scale up, expanding from an initial intake of 25 In line with these gaps identified, main points first-year medical students in 1998, to 70 per year raised during the consensus workshop were in 2010. The Tanzanian Government assisted this organized in two parts. First, participants identified by providing student loans and grants to private challenges encountered in establishing and running school students, enabling more students to afford medical schools in low-resource settings in sub- tuition fees (11). The number of teaching staff Saharan Africa. Second, best practices from each (salaried full-time or part-time, and volunteer) at represented medical school were listed and used to 51 of 98 responding schools is fewer than 100, develop recommendations on the minimum about half have between 52 (25th percentile) and requirement for establishing medical schools, 147 (75th percentile) teaching staff. Small salaries, based on the World Federation of Medical limited career options, heavy teaching loads, Education (WFME) standards. growing enrolment, and absence of equipment and support staff are the main barriers to retaining LITERATURE REVIEW faculty staff (11). Deficiencies in medical education In the late 1999, the World Federation of Medical infrastructure are ubiquitous and restricting. At Education (WFME) started to develop a set of Jimma University, electricity, water, and standards to be used for the global accreditation of telecommunications are unreliable, jeopardising medical schools (15). This set of international training and innovation. At Ibadan University, standards addressed the process of medical informants expressed concern about daily power

280 Ethiop J Health Sci. Vol. 26, No. 3 May 2016 outages. Departments have to purchase generators achieve these needs are more the real underlying for clinical and teaching functions. At Catholic problems. In such an environment of lack of University in Mozambique, challenges include expertise, the financial and procurement insufficient number of computers, restrictions in regulations have turned out to be bottlenecks internet connectivity, and absence of student hindering the timely utilization of money towards hostels. Inadequate student housing near clinical the academic needs of teaching and research. sites is also a difficulty at Walter Sisulu University Lack of infrastructure, facilities and support is and Mali University (11). demonstrated in the shortage of laboratories, class Insufficient coordination between the rooms, practical sites (hospital facilities) and skill ministries of education and health can be a barrier training labs. Teaching facilities, transportation, to medical schools’ ability to increase the capacity information communication technology (ICT), lab of the health workforce. The coordination between consumables, e-libraries, cadavers and other these two ministries was a problem in almost all necessary inputs are compromised either due to countries visited. The ministry of education planning, prioritization, or lack of efficient generally provides funds for medical schools, utilization of budget. whereas the ministry of health is the main In post-conflict settings such as Somalia, employer of school graduates. In many countries, Somaliland and South Sudan, establishing medical coordinated planning for budgets, priorities, and schools commonly face seven more problems due outcomes between the ministries of health and to destruction of infrastructure and massive education is poor, which contributes to migration of staff. In recruiting and retaining inappropriate curricula and the graduation of faculty, security issues top all other priorities. doctors who cannot find employment in the Moreover, governments often tend to be inclusive country. In Mali and Sudan, the number of medical at the expense of quality of service. graduates substantially exceeds the in-country Systematic and regular evaluation of capacity to hire new physicians, despite the need educational process, output and impact at all levels for better health services (11). is crucial for accreditation and certification of medical schools but is a challenge. For instance, in Challenges in establishing and running medical Ethiopia, although there are more than 30 school: There is often lack of guiding, favorable recognized and operating medical schools, there policy and genuine commitment for the seems to be no systematic and regular external or coordination between ministries (the Ministry of internal evaluation and accreditation procedures. Education and Ministry of Health) involved in the Higher Education Relevance and Quality Agency production and consumption of trained human (HERQA) provides accreditation in Ethiopia when resource. Lack of clearly defined responsibilities an institution is initially founded but mainly serves and mandates of various stakeholders is another for private medical schools. The team composition shortcoming. of the quality assurance bodies often lacks The increasing number of students has not mandated health professionals. The application of been commensurate to the required capacity of a non-contextualized evaluation tool as is in the educational resources and faculty. Scarcity of case of HERQA may reflect this gap. biomedical and senior clinical staff is a serious Regional hospitals are not usually equipped limitation.This mismatch is essentially due to and staffed with the standards required for medical inadequate strategic planning by stakeholders and education and training of students. In addition, poor autonomy of medical schools. Academic there is inherent conflict of interest where the leadership and qualified administrative staff to teaching hospitals are under the Health Bureau deliver a good administrative support is also in while the school is under the Ministry of short supply. Education. This scenario sometimes creates a Financial scarcity to procure adequate problem on how to use the money allocated for equipment and recruit the necessary experts and training of medical students in these hospitals. faculty is common. However, sometimes the lack However, many schools reported progress in of strong and qualified administrative support to accreditation of institutions and assessment of manage finances and other related activities to graduates. In Mozambique, the newly formed

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Medical Council plans to develop accreditation unsuitable design that creates a hurdle rather than a standards for medical schools and external support to various faculties and staff. examinations for medical students (11). In Ethiopia Best practices and recommendations for and the region, there is a demand for a higher establishing medical schools: The local schools number of enrolling medical students and quality have fulfilled some of the best practices depicted doctors in limited teaching environments where the in the WFME recommendations. The mission of population is growing exponentially and the the World Federation for Medical Education projected population growth is happening rapidly (WFME) is to enhance the quality of medical in future years. To address these challenges, a education world-wide, thereby promoting the consensus workshop was incepted with the goal to highest standards in medical education. address required objectives in running and establishing medical schools in the region with the Institutions must have institutional autonomy. use of instruments including WFME global There should be appropriate independence from standards for medical undergraduate education government and other counterparts in matters of (10) and Higher Education Relevance and Quality academic methods and environment while keeping Agency (HERQA). a strong accountability. This will enable Human resource management is a major institutions meet government overall goals and challenge that requires expertise and well-defined objectives of producing competent and relevant strategy. Creating mechanisms for staff professional graduates who would address societal development and career promotion helps to problems effectively. motivate and retain them, but this is inadequately Students’ admission to medical schools based practiced. Staff recruitment requires strategies to on the national qualifying examination after two attract employees through various material and years of college preparatory education (11th and non-material incentives, which are also scarce. 12thgrades) is an important step but is insufficient Training staff in medical education is one area of to ensure competence at basic level. Although staff development which benefits both the quality placement of students with the highest board exam of education and the faculty member, who will not score is being practiced, there is no system for only apply scientifically verified teaching methods screening and recruiting those who are intrinsically but also involve in research for educational quality motivated and appropriate for the field and identify development. Lack of representation of academic students with special needs. staff from medical educators in top management Involvement of students in curriculum may affect prioritization of educational problems development, review and quality assurance has and subsequent allocation of budget to address given impetus to the educational programs in many them. of the schools. Thus, students need representation Communication gaps between school in academic councils, committees working on administrative wing and academic wing and the curricula and quality assurance. hospital is wide. School networking, collaboration, Medical schools are able to select new partnership, link with national and international graduates based on performance and recruit them organizations and stakeholders is minimal for most to be academic staff after negotiation with MOH. of the schools. This helped the schools in increasing the number There are factors that lead to poor motivation of staff and also in implementing staff retention staff in teaching and research activities. Staff are mechanism by providing further training usually overloaded and give different services opportunites. simultaneously. The poor facilities, the inadequate With regard to development of the educational allocation of budget for research, and lack of program, there is a strong culture of working on reward system for meritorious activities are cited. curriculum development among universities. There Conducive organizational structure is a is also participatory involvement of the faculty prerequisite for efficient leadership, from within and stakeholders such as MoE, and communication, appropriate use of time and MoH from outside the universities. financial resource. However, sometimes there is Academic staff/faculty attraction, retention and motivation mechanism should be enhanced.

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Recognizing best instructors, researchers, and skills can alleviate the problem. Medical department, and free scholarship for family schools should have their own hospitals; where members are some of the strategies to adopt in this there is no such facilities, there should be MOU regard, but are not widely practiced. The with other hospitals. government must take into account teacher-student Program Evaluation should include tracking ratios relevant to the various curricular graduates (tracer studies) and giving feedback to components. Staff retention strategies should be instructors. A tracer study of graduates from all designed in medical schools through a variety of disciplines was done by Jimma University in 2012 means. This can be done by applying a clear staff which identified good qualities of graduates and recognition and merit-based promotion strategy. gaps perceived by their employers (17). Similar Faculty development on effective teaching skills, kinds of tracer and cohort studies should be done student assessment, curriculum revision, research specifically for medical school graduates. methodology, manuscript writing as well as Evaluation of faculty by the students is a through long term trainings (PhD, specialty and standard practice by all colleges which is a sub-specialty, MSc) will help in retention of staff. prerequisite to the promotion of each faculty at all In collaboration with partners, the or many of the colleges. However, this evaluation establishment of Health Sciences Education should include courses and the tool should be Development Center (HSEDC) has enhanced regularly updated to reflect changes in the training of staff in Medical Education and educational system. organizing short term and continuous trainings on Introduction of systematic and continuous instructional skills, design, and student assessment. quality assessment and evaluation framework Each institution should open HSEDC to organize should be embedded into the system of medical trainings in instructional skills, design, student schools. A national medical council should be assessment protocols, curriculum review to include established to give accreditation of new schools, innovative methods of teaching and medical monitor quality in existing schools, and prepare education module in the curricula, to encourage qualifying examinations. Professional associations educational research, organize skill lab and should be present in the peer review and site visit evaluate the quality of medical education on across medical schools. regular basis. Governance and administration should not be Educational resources such as owning a neglected. A forum should be established to create hospital and constructing modern hospital is a win-win solution between the government and essential and many of the colleges particularly in the institutions. Training of the administrative staff Ethiopia are in the process of doing so. For is essential and is to be enhanced. Consensus for a instance, Jimma and Gondar universities are clear and acceptable organizational structure building and equipping state of the art hospitals, should be designed to achieve efficiency and while Mekele and Hawasa universities have effectiveness. already done so. Some universities like the With regard to governance and administration, University of Gondar have established simulation most schools have very good communication with centers, which assist clinical skill teaching top management of the respective universities. specially in the context of a high student-patient There is some planning to allocate budget for ratio. Using anatomical models is also similarly required resources, but further decentralized helpful and is commonly practiced in nursing authority to utilize and account for the finances are training and should also be encouraged for medical not yet functional. At the university level, there are colleges. Self-directed learning and accesses to different ways of generating additional incomes reading materials should be increased using e- but this should be decentralized enough for the books and e-courses. Government and schools to acquire financial autonomy and benefit stakeholders should be involved in scaling up from it. educational resources. Collaboration and Many of the schools have the freedom to build networking between institutions should be given partnerships and collaborative links which have high priority. Joint procurement of standardized flourished over the years. For instance, Jimma equipment and exchange of educational methods University and University of Gondar have links

Establishing Medical Schools … Tsinuel G et al. 283 with UK and German schools such as Nottingham, m_docman&task=doc_download&gid=7130& Leicester and Ludwig-Maximilians-University. Itemid=2593 Accessed August 25,2015 3. Pankhurst, Richard. An Introduction to the ESTABLISHING MEDICAL SCHOOLS: Medical History of Ethiopia. Trenton, New RECOMMENDATIONS Jersey: Red Sea Press, 1990: 139-264. 4. Yifru Berhan. The Evolution of Modern This section concentrates on quality standards for Medicine in Ethiopia. In: EnawgawMehari, establishing and running medical schools in the KinfeGebeyehu, ZergabachewAsfaw’s The settings of limited resources and rapid growth of Manual of Ethiopian Medical History. People educational capacity in Sub-Saharan Africa, to to People. 2012:18-23. Available better meet the needs of evolving health care at:http://xa.yimg.com/kq/groups/4606997/118 systems in the future. 2686633/name/forAccessed August 25, 2015 1. The curricula should be horizontally and 5. Federal Democratic Republic of Ethiopia vertically integrated Ministry of Health. Health Service 2. The government should develop and Providers.Available at implement proper strategic planning and http://www.moh.gov.et/hsp. Accessed in Dec guiding rules before establishing medical 11, 2013 mchools 6. Berhan Y. Medical doctors profile in Ethiopia: 3. The should be a network of medical schools production, attrition and retention. In memory overseen by central governing body for of 100-years Ethiopian modern medicine & resource sharing. the new Ethiopian millennium. Ethiopian 4. There should be sufficient autonomy in medical journal, 2008;46:1-77. allocation and utilization of resources by 7. Grover A, Niecko-Najjum LM. Physician medical schools in accordance with their ever- Workforce Planning in an Era of Health Care growing need which is assessed by all Reform. Academic Medicine, 2013; stakeholders involved. 88(12):1822-1826. 5. There should be a functional monitoring and 8. Burgis‐Kasthala S, Kamiza S, Bates I. evaluation framework for the program Managing national and international priorities: relevance, learning outcomes of graduates, a framework for low‐income countries. governance, academic and support staff, Medical education, 2012;46(8):748-756. educational resources, curriculum, teaching, 9. Clancy GP, Duffy FD. Going “All In” to learning and assessment, student support, Transform the Tulsa Community’s Health and research and student exchange activities, Health Care Workforce. Academic Medicine, collaboration and networking activities, and 2013;88(12) :1844-1848. quality assurance in all medical schools using 10. Frenk J, Chen L, Bhutta, Z.A, et al. Health the customized HERQA tools. professional for a new century: transforming education to strengthen health systems in an REFERENCES interdependent world. Lancet, 2010;376(9756):1923–58. 1. Federal Democratic Republic of Ethiopia 11. Mullan F, Frehywot S, Omaswa F, et al. Ministry of Health. Health and health related Medical schools in sub-Saharan Africa. The indicators 2010/11. : Federal Lancet, 2011;377(9771), 1113-1121. Democratic Republic of Ethiopia Ministry of 12. Majumder AA, D’Souza U, Rahman S. Health. Trends in medical education: challenges and Availableat: http://www.moh.gov.et/English/R directions for need-based reforms of medical esources/Documents/Health and Health training in South-East Asia. Indian journal of Related Indicators 2003 E.C.pdf. Accessed in medical sciences, 2004;58:369-380 December 2013. 13. Broadhead RL, Muula AS. Creating a medical 2. Ethiopia, Factsheets of Health Statistics school for : problems and 2010,World Health Organization, achievements. British Medical Journal, http://www.afro.who.int/index.php?option=co 2002;325(7360):384.

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APPENDIX 1: LIST OF ALL Wollega University, Ethiopia PARTICIPATING INSTITUTIONS WITH Dr. Bilisum Mulatu Tasisa NAMES OF PARTICIPANTS Debre-Berhan University, Ethiopia Jimma University, Ethiopia Dr. Getenet Molla Prof Abraham Haileamlak Mitikie Dr. Hailemariam Segni Abawollo UCM Beira, Mozambique Dr. Tsinuel Girma Nigatu Dr. Nadia Tavassinha Sitoe Dr. Tsedeke Asaminew Alemu Dr. Tesfaye Kassa Tefera , Republic of South Sudan Prof Jino David Ladu Meleby Arba Minch University, Ethiopia Prof Mayen Machut Achiek Mr. Berhanu Merdokios University of Hargeisa, Somaliland Mekele University, Ethiopia Prof Deria Ismail Ereg Dr. Fasika Amdesilasie Gebrekirkos , Somalia Adama Science and Technology University, Hassan Warsame Nor Ethiopia Dr. Legesse Tadesse Wodajo Ludwig Maxmillians University, Germany Prof Siebeck Matthias Jimma University Chronic Disease Project, Prof Martin R. Fischer Ethiopia Mr. Fabian Jacobs Dr. Yoseph Mamo Azmera

Debre Tabor University, Ethiopia Dr. Biniam Ewnete Zelelew