Education and training for health professionals in the emerging market economies:
A literature review
Manisha Nair
Premila Webster
1
Abstract
Background: Along with economic growth and social reforms, the emerging market economies (EME) are also undergoing restructuring of their healthcare systems. There is now an increased focus on disease prevention and primary care along with a patient-centred approach. However, this needs to be complemented by alterations in the health education system. This paper highlights the current challenges in education systems in the EME and some possible solutions.
Methodology: Review of the published literature in the last 10 years.
Results: The issues identified are mismatch between the health needs of the population and the education curricula, out-dated curricula and teaching methodology, growing number of medical schools, quality of education, inadequate guidance for students to select health profession as a career and field of specialisation.
Possible solutions: The literature provides evidence of innovative approaches adopted in several EMEs which includes – outcome based education, community oriented medical education, problem based learning, initiatives to improve quality and resolving the shortage of skilled educators for medical and nursing schools.
Acknowledgements
We are grateful to Professor Harold Jaffe, Dr Kenneth Fleming and Mr. Ian Scott for their invaluable insights and guidance during this literature review.
We are thankful to Mr RamonLuengo-Fernandez for translating the Spanish literature.
We thank Mr Philip Bassett at the “Knowledge Centre” for extending support in searching the Spanish and Portuguese literature.
Table of contents
Background...... 1
Methodology...... 1
Results...... 2
Issues identified...... 2
1. Mismatch between health needs and education...... 2
2. The impact of the unprecedented growth of medical and nursing schools...... 2
3. Career choice of students...... 3
Possible solutions...... 3
1. Updating the curriculum...... 4
A. Outcome-based medical education...... 4
B. Community-oriented medical education...... 5
C. Problem-based learning/teaching strategy...... 6
2. Initiatives to ensure quality of education...... 6
3. Educators...... 7
Conclusion...... 8
References
Appendices...... 12
Appendix-1...... 12
Appendix-2...... 13
Appendix-3...... 20
1
Background
The Emerging Market Economies (EME) have achieved unprecedented economic growth in recent years and undergone political and social reforms. While most of these countries are undergoing rapid epidemiological transition resulting in a combined burden of communicable and non-communicable diseases, and injuries among the population, their health systems and healthcare workforce are not set up to handle these changes [1]. There is now a growing awareness of the need for reforms in health systems and a change from an acute care model to a patient-centred public health model [1].
While these countries are in different phases of their healthcare reforms there is a common focus on shifting from secondary to primary care, understanding the population dynamics of diseases along with the patient’s perspective and emphasis on both cure and care [2, 3]. The countries of Eastern and Central Europe such as Russia and Poland are in the process of replacing the Soviet model of clinic based specialist care to a system of integrated general practice [4-6]. Similar reforms are being undertaken in the Latin American countries of Chile [7], Argentina [8], Brazil [9], Mexico [10] and Peru [8]. Colombia aims to achieve the goal of social transformation and equity in healthcare by strengthening their primary healthcare systems [11]. Countries in East and South-East Asia - India, China and Thailand are undergoing major transformation in healthcare to meet the needs of the rural and underserved population [12-14].
The reforms in health systems need to be complemented with reforms in educating health professionals. This will require an understanding of the existing education systems, their relation to the health needs of population and the impact of globalisation and technical advancement. This literature review attempts to identify some of the issues faced by the health education systems and offer possible solutions.
Methodology
A systematic review of published literature, limited to the last 10 years was conducted to include recent updates on medical and nursing education (Appendix 1). There is a vast literature for each of the EMEs specifying their individual health needs in relation to speciality health care. This review covers only the common issuesrelated to education and training in these countries.
Results
Issues identified
The following were the issues identified in relation to challenges faced by the health education systems in the EMEs:
1. Mismatch between health needs and education
Though EMEs have specific needs in terms of speciality care, they share common concerns related to mismatch between health needs and education. A study conducted in nine countries namely, Chile, Cuba, Egypt, India, Philippines, South Africa, Sudan, Sweden and the United States identified similar issues in the healthcare training programmes relating to balancing the teaching of clinical competence and population perspectives [15].
While almost all EMEs are undertaking health reforms to move from a specialist to integrated general practice resulting in a sudden increase in demand for General Practitioners (GP), teaching is concentrated on specialisation in advanced technology and disease areas ignoring common health problems at the population level [16]. Focus group discussions conducted among final year students in two universities in Malaysia showed that there is a poor understanding of the discipline of general practice and most of the students are unable to relate their training to actual practice in the community [17]. However, a study conducted in Jordan has found that community-oriented training, large programmes in primary care and faculty role models positively influence medical students to select family medicine as a career [18].
There is consensus that for healthcare reforms to result in long-term benefit, key changes in the curriculum and innovative methods in training health professionals are needed [19]. The literature suggests that change is often difficult in inherently conservative professions such as healthcare especially in a less established and disintegrated healthcare system [20] in large countries like India, China, Brazil and Russia.
2. The impact of the unprecedented growth of medical and nursing schools
With economic growth and liberalisation there is a steady growth in the number of medical schools in EMEs(especially in the last decade or two) which enrol a great number of students producing thousands of physicians annually. Privatisation has played a key role in the economic growth of these countries which is reflected in its growing influence in health education [21]. Private medical and nursing schools are growing at an accelerated rate in Latin America [22], Eastern and Central Europe as well as in East and South-East Asia [21]. While the private market has grown, it is mostly unregulated as a result of which most private universities and teaching hospitals do not provide standard quality education. In Chile there is one medical school for 675,000 inhabitants compared to one for 2.4 million in the US and 3 million in Canada [23]. The Chilean healthcare teaching universities have about 60,648 students leading to a collection of US$250 million tuition fees, but only 9.8% of these teaching programmes are accredited [22, 24].
Another example is India, where the number of medical schools has almost doubled in last twenty five years producing the largest number of doctors (about 30,408 per year) in the world [14]. There were 271 medical schools in 2008 recognised by the Medical Council of India (MCI) with inequity in distribution between the states [14, 25]. The private schools are growing at an increased pace [21] leading to a lack of adequate supervision, impacting on the quality of education [14, 25, 26]. Another challenge is the shortage of educators for the increasing number of students which has further led to a compromise in overall quality [14, 25].
While research shows the existence of explicit accreditation systems in Argentina, India, Malaysia, Pakistan, Philippines and South Africa for quality assurance of undergraduate medical training programmes [27] the implementation of accreditation is variable[14, 25, 28].
3. Career choice of students
While discussing education systems it is important to understand the factors that influence students’ selection of health profession as a career and the field of specialisation. The results of studies to assess career choice among medical students in some EMEs i.e. Tunisia, Turkey, Jordan, India and Egypt are comparable. More than 95% of the students wish to specialise, however less than 10% want to study family medicine [29]. GPs are often at a disadvantage compared to specialists in terms of salary, work environment, professional recognition, supporting financial and administrative infrastructure, and personal and professional growth [5, 9, 30-32]. The status of general and family practitioners is not as high as that of specialists [33]. While 30-40% of students want to work in rural communities, this is only for a short period of time and mainly to gain experience [29]. These studies have identified prestige, social status, better financial opportunities and personal growth as reasons that influence students to choose a medical career [14, 18, 29, 34, 35].
Most students appear not to have an understanding of what is involved in working in health care while making a decision to take up a medical career. In 2000, the Faculty of Medicine, Siriraj Hospital, Thailand adopted an innovative approach by allowing 115 students selected for medical training to assist in government hospitals and experience the responsibilities of a physician before embarking on their medical career [36].
Possible solutions
The literature suggests that most EMEs need to modify their education system to cater to the health needs of their population. Educational curricula appears to be out-dated in relation to the learning and teaching methodology [37] and teaching is concentrated on specialisation in advanced technology and disease areas ignoring common health problems at the population level [16].
1. Updating the curriculum
Two models of curriculum planning namely; SPICES (developed by Harden et al. in 1984) and PRISMS (developed by Bligh in 2001) have transformed the philosophy of medical training from a “teacher-centred” approach to a “student-centred” approach [38]. Both models focus on outcome-based, community-oriented, problem-based learning approach (table-1), an integrated curriculum structure and teaching, and an explicit mode of evaluation [38]. The process of curricular reform undertaken by the School of Medicine Tec de Monterrey, Mexico, highlights ways to bring about change. To overcome the resistance that arises mainly from faculty concerns and to increase the ownership of clinical and basic scientists, teachers and students, a curriculum committee with seven sub-committees comprising of these stakeholders were created [38]. These committees were assigned separate tasks related to needs assessments of the health system, curriculum review of other countries, identifying gaps in existing programme, preparation of timetable and course syllabi and defining the outcomes [38]. A follow-up of implementation of the updated curriculum provided evidence of a gradual but smooth transition from the existing to the new curriculum [38].
Table 1 Models for curriculum planning
S / Student-centred approach / P / Product focused and practice basedP / Problem based learning strategy / R / Relevant to outcomes planned
I / Integrated curriculum structure / I / Inter-professional in character
C / Community orientation / S / Short courses and small group learning
E / Elective study modules / M / offered at Multiple-locations (hospitals, ambulatory clinics, rural settings, etc.)
S / Systematic curriculum planning / S / Symbiotic
Source [38]
The following are a few examples of innovative methods of curricular reforms adopted in the EMEs:
A. Outcome-based medical education
Outcome-based education (OBE) proposed by Spady in 1988 [39] has been implemented in Switzerland, Netherlands, Scotland, Canada, USA, UK, India and China [39]. OBE is different from the traditional approach to curricular reforms in that it is focused on the outcome (i.e. doctors who are professionally and ethically able to undertake the necessary clinical tasks) and not the process of education [40]. Therefore the first step in this approach is to list the outcomes desired by a country in accordance with the health needs of the population and the global minimum essential requirements (GMER) [8]. This is followed by a detailed description of the curriculum and tools required to achieve these outcomes. In April 2005, in the XLVIII national meeting of the Mexican Association of Medical Schools, 120 deans and faculty members from diverse medical schools participated in defining the outcomes of medical education for Mexico [39]. Nine outcomes were selected which included (i) clinical skills, (ii) communication skills, (iii) public health and health systems, (iv) scientific basis of medicine, (v) information management, (vi) critical thinking and research, (vii) teaching skills, (viii) administrative and legal skills in medical practice and (ix) values, attitudes, ethics and professionalism [39]. The advantages of OBE are that each country can set their goals according to the health needs of their population, the pre-defined outcomes act as the yard stick for measuring the quality of teaching and it identifies gaps in the curriculum [40]. However the concept is relatively new especially in EMEand evidence of its success is not yet available.
B. Community-oriented medical education
Another innovation in healthcare is the client centred approach which has made community “the central institutional goal” [41]. Educational institutions provide a thorough knowledge of community-oriented primary care and primary prevention at population level [41] through balanced training in “Family medicine” [3]. A study which included focus group discussions with students, teaching faculty, healthcare providers and consumers showed a poor understanding of community needs among students [42]. The first step in its implementation is to bring the classroom out of the wards and into the community [41, 42] which can be followed by community-based projects for students with good mentorship [41]. The method adopted by Tartu University in Estonia (described in fig-1) to incorporate family medicine into the traditional academic curriculum is an example of success in combining clinical care, research, teaching and healthcare at population level [43].
Fig-1: Training of family doctors in Estonia (2002), retraining of the existing primary care physicians shown in the dotted box was done between 1991 and 2002 along with training of new medical graduates(Adapted from [43])
C. Problem-based learning/teaching strategy (PBL)
The concept of PBL was introduced into medical training by the McMaster University of Canada in late sixties [44]. The primary advantages of PBL are medically relevant integrated curriculum, contact with patients, student-centred approach and small group learning methodology [45]. PBL has been found to be superior to traditional lectures in medicine and dentistry in Malaysia [44, 46]. Students were able to efficiently link basic sciences to clinical appraisal and were actively involved in achieving the learning objectives [46]. However the same study also highlights its disadvantages showing that its implementation is expensive and requires trained faculty. Further it could be sometimes stressful to the students or they may deviate from the key learning objectives if the PBL sessions are not conducted effectively [46]. Another case study at the Nelson R. Mandela School of Medicine in South Africa found PBL to be highly acceptable among students who failed in their second year of a traditional medical course [45]. These students were able to perform better than those who chose to continue in the traditional curriculum and acquired a more humanistic and holistic approach to the practice of medicine.
2. Initiatives to ensure quality of education
There have been several initiatives by the World Federation for Medical Education (WFME) to develop a common international standard for medical education. While accreditation is an effective quality assurance tool, the procedures and policies for accreditation vary across the countries [47]. The WHO/WFME Guidelines for Accreditation defines the essential elements for the process; however this needs to be adopted globally [47]. WHO is attempting to develop new Global Directories of Health Professions Education Institutions (GDHPEI) with the objective of capacity building to provide technical updates to the health professionals and for monitoring their educational background, developing a tool for regulation of educational capacity and establishing/strengthening of national accreditation systems [47]. The Institute for International Medical Education (IIME) has taken up the process of developing “global minimum essential requirements (GMER)” to standardise the quality of physicians around the world [8]. Its primary focus is “outcome” instead of the “process” of medical education [8]. GMER identifies seven domains; (i) professional values, attitudes, behaviours and ethics, (ii) clinical skills, (iii) communication skills, (iv) scientific foundation of medicine, (v) information management, (vi) population health and health systems and (vii) critical thinking and research [48].
3. Educators
The teaching faculty is the major link between a good educational curriculum and the final product (i.e. doctors and nurses). In order to be able to deliver the required skills to future health professionals, these educators should be trained and equipped with necessary teaching skills. Several countries have adopted cross-cultural exchange programmes aimed at developing teaching skills, leadership and professional bonding among medical educators around the world [49]. Health educators trained in high-income countries in technical and teaching skills return to their home institution and apply the skills gained to train both health professionals and other faculty. Thus an international network is created that keeps itself updated on the changes in the health sector through distant learning and internet discussion groups [49]. Leading examples of such initiatives are the Foundation for Advancement of International Medical Education and Research (FAIMER) institute in the US [49] and the Public Health Foundation of India’s (PHFI) Future Faculty Programme [50]. Such endeavours have been found to be effective in two very different cultural settings. The Stanford Faculty Development Programme (SFDP) of the US was piloted in the Kazan State Medical University (KSMU) in Russia [51]. An evaluation study showed that despite the difference in culture, medical curriculum and philosophy of teaching, this pilot project was successfully adapted in the Russian University which improved the technical skills of medical faculty and contributed to their professional and personal growth [51]. The Medical Education Department in the Faculty of Medicine, Suez Canal University, in Egypt [52] developed a distance learning diploma in health professional’s education supported by the Egyptian National Quality Assurance and Accreditation Agency and the Eastern Mediterranean Regional Office of the World Health Organization (EMRO-WHO) that included all the medical education domains. This approach improved professional and technical ability of physicians and minimised the cost of training and displacement of health professionals to other countries for training purposes [52].